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PAYMENT <br /> SAN JOAQUE! IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECE VED <br /> MASTERFILE RECORD INFORMATION FORM SEP 1 l 2008 <br /> ❑New EH Program at Existin Facility w 1311 nPr--o and New Facility SAN JOAOUIN COUNTY <br /> Facility ID <br /> Pro ram Record ID K-� S'c�-� HEALTH DE qR MENT <br /> Facility Address l�j �y <br /> (Please Check the appropriate description and specify ElLe,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 20 Square Footage Food Handlers Course required: YEs No 13ne <br /> estau <br /> nt: Seating Capacity Sq ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only <br /> Color Type ype <br /> ❑ Mobile Food Vehicle--Make VehicleSticker# <br /> Registration# License# <br /> ❑Mobile Food Prep Unit—Make Vehicle <br /> # Sticker# <br /> hicle Type Color <br /> Registration# 11 Ice Plant <br /> 11 Temporary Food Facility—Dates of operation from to <br /> ❑ Special Event —Dates of operation from <br /> to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispeoser—Number of Containers in Multi-Head Unit <br /> - CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(?200)- ❑Recycle/IExemp t S stem(2299) <br /> 13 Hazardous Waste Generator. Torts Generated Per YeYear3 <br /> ❑CRT Offsite Handlers(2216) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Pemnit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> -UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms - <br /> HOUSING PROGRAM(2400) <br /> D Hotel/Motel—Number of Units Jail or Exempt Institution—Numbvx of Units <br /> Employee Housing(2700)Use Fmpforej HausingAAbor Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑Spa ❑Out of service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑Kennel <br /> ❑Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) El Body Piercing(4120) ❑Permanent Cosmetic(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill 13 Transfer Station 13 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cuyd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS ETTD 46-02-003 Btne Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON -S'¢i't' C"�tC Day Ph Night Ph <br /> PROGRAM ELEMENT FEE 2-&0 ❑ Surcharge FEE - ❑ Otber FEE <br /> I 2! ' <br /> INSPECTOR# � I �' � / PERMIT VALI ❑ Food Handler <br /> D �.1 � O � t0 � 1�=/ - � <br /> ] check# _ AMOONTPAID of�] Date N INVOICE# <br /> 0 Cash REVIEWED BY ACCGVNTING OFFICE L- Date <br />