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2013-02-26 09:26--aw $ 655mgr % 11111111 > 2094688392 P 2/2 <br /> SAN SOAQUIN COUNTX'ENVIRON1Y-E,NTAL)M,ALTH DEPARTMENT <br /> MASTERmr!,RECORD•INFOMATION FORM <br /> ❑Ncw BH 1roWarn at Existin FACIII(Y CINGWERProgramandNeWFACIlity <br /> FacilityID Pro am Record ID <br /> Facility Address t'�rELRDVr•rE LM - LQh I -S <br /> (Plcax,Check the appropriate description end specify Lk:T,p_umber of units and petlinent Information.) <br /> FOOD PROGRAM(1600) <br /> E3 Restaurant' Seating Capacity Square Footage Food ndlers Course req auired:. yrs❑ Pio 13 <br /> ❑Commissary , O Dry gorage only ❑with Food Pieparation ❑Ytsiding I&&Incs Numbs ofUnits <br /> 0 Retail Market—Square footage ❑with Meat Market only 13 Multiple Departn=ts ❑Prepackaged Goods Only <br /> 0 Mobile Food Vehicle---Iv(alcc Vcbielo ype Color <br /> Registradon# License K Sticker# <br /> 17 Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration a Licensc# 5aetcer# L <br /> ❑Temporary Food Faeillty--,Dates of operation frost to 17 Ice mat <br /> 0 Special Event --Dates of operation from to ❑Produce Stand <br /> • �AIRYPROpRAIVI,(2000) . <br /> ❑Grade A Dairy ❑Gradc B Dalry ❑Milk Dispenscr---Number of Containers in Multi-Head Unit ' <br /> quVA ❑State Facility Surcharge(2399) <br /> IL&7ARDOUS WASTT PROGRAM 9L=)' <br /> ❑llawdous Waste Covera(ori---Tons Generated Per Year_ - _ .13 Recycle/Exempt System(2299) <br /> ❑CRT Offsite Aandlen(me) ❑Silver Qtly(x222) ❑Appliance Rocycl=(tin) <br /> Tiered Perr iitt(ng FAcipty ❑C.ondition4y AtAhorizcd(CA) ❑CwdWonally Exon pt(CE) <br /> ❑Pcnnit--ByRuu Fizcd Unit ❑rwmit-By Rulc Household Hazardous Wasto <br /> ©AnoveGILOUND STORAGE TANK FAcmm(AST)(2390) Numbs of AST <br /> .UNDERGROUND STORAGE TANK NM PROGRAM(2300)Usc rfs7 ,A and is tunas <br /> HOUSING PROGEM(2t00) <br /> ❑HotdoMotel Number of Units .Cl Jail or Exempt Institution Number oruaits <br /> k600Teo HousWC(2700)Use3serrnloW,x►fouuar/Ia6ur rami,A k izot,Fom <br /> Oig Mf7'IGAVON(2900) UNDr-.RGROUND INJECTION 00NTROI{3000) <br /> .0 Environmental Assessment ❑UST-CAP Site -❑LocaI HW Cleanup Site, ❑NPIBEr Cleanup Site ❑UIC Site <br /> 0 Abandon ed HW Site 13nod-NPIJSEP acanup Sitc Cl RWQCR Cleanup Site site <br /> B§GR__=-ONAr.HEjALTjII- iOGRAM(3(,00) <br /> Numberof PooWSpas at Facility. (3 P901 Q Spa ❑Out of Service ro9ppa Natural Ilathing Arca <br /> VECTOR CONTROL.PROGRAM(4000) <br /> ❑Paultry Fatten Maximum number of birds 0 Kennel <br /> T'AT'r00.QOdY PIERCING.PERMAiiINTGO;ME0!Q,j:R0GRAM(4100) <br /> XTattootng(4121) ❑Sod?ria cing(4120) ❑rerraxnent Cosmetics(4122) <br /> 11JgUID WAZU PROGRAM(4200) <br /> E Pumper Vehlele-•ReSL'U tion# uoewe# Capacity Vehicle-it <br /> 13 Pamper Yard O Patk rreTreatment Plant. ❑Qrcmlcal Tolicfs Nuwber pf Units <br /> SQLID hAUF.PR0GgAM,(44'00) <br /> Q IAndfdl ❑Transfer Station ❑AC/Cannery Waste Site 0 Sludcc/Ass Site <br /> 0 Waste Tire Facility ❑Compost Facility ❑Processaecycle Facility ❑CIA Andlill Site <br /> 0 Refuse Vemcles--Nun-a=of Units ❑Dump ors>20 Cu yd—Number of Units ❑FarmlRauch Cleanup 61te <br /> EM bICAL_WASTE PROGRAM(4500) <br /> ❑Primary Gro 13 Acute Care ❑Skilled'Nursing ❑barge Generator Q Small Generator Q Limited Basler <br /> ❑Transfer Stitiou ❑Veterinary Came Cl Common StoraCe Facility—❑2-10 ❑ 11-6o—❑>60 genemtors <br /> PUALIO WATER SYSTEM PROGRAM(4600) BJueAjm4iWd0n Form <br /> Em ROCNc:Y N r-CATION FOR TIVV F&LCKLITY AHa OR PROGRAM <br /> CONTACT PERSON C bay Ph 2 D°l�ZIA3.606 Night Ph <br /> PROGRAM EIXMrNr ( FEE � 1:1 Suraargcnx . 13 Other FEE <br /> INsmcroAv '[I�z rFRMR'VAL1D . to c3Food Madlcr <br /> (t `ac e( �i.�47&Jj2 OUNT PAm , 12. 1, — Date P- <br /> 1 irtv4ua±# <br /> ❑S.acA R13�IAwE1�by AccotkmN0 0►ncu nate <br /> ••�,••,• Masterfile Roeoe4l'Ink <br /> Received Tlme Feb, 26. 2013 9 : 29AM No. 0494 <br />