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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION,FORM RECEIVED • New EH Program and New Facility NOV 4 2201 ❑ New EH Pro ram at Existing Facility 2 Program Record ID J SAKI JOAQUIN COUNTY Facility M � 7� ENVIROMENTAL Facility Address + HEALTH DEPARTMENT {Please check the appropriate description and specify size, number of units and ertinent information.} FOOD PROGRAM(1600) Square Footage Food Handlers Course required: Yes [I No ❑ ❑ Restaurant: Seating Capacity ❑Vending Machines Number of Units. ❑ Commissary [3 Dry storage only ❑ with Food Preparation ❑ wlMeat Market only [3 Multiple Departments❑ Prepackaged Goods Only ❑ Retail Market----Square footage �� Vehicle Type Color .Mobile Food Vehicle--Make License# Sticker# Registration# Vehicle Type Color ❑ Mobile Food Prep Unit--Make License# Sticker# Registration# to ❑ Ice Plant❑ Produce Stand ❑ Temporary Food Facility--Dates of operation fromto ❑ CFO ❑ A ❑ B ❑ Special Event---Dates of operation from DAIRY PROGRAM (2000) C1 Milk Dispenser-Number of Containers in Multi-Head Unit ❑ Grade A Dairy ❑ Grade B Dairy CUPA Number of chemicals: y� ❑ Hazardous Materials Business Plan (1900) ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazard Program > Tons Generated Per Year^ ❑ Hazardous Waste Generator{2200}---------- ❑ PBR HHW(2236) ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234, 2235, 2237) ❑ PBR (2231) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ ,Jail or Exempt Institution ----Number of Units_ ❑ Hotel/Motel------Number of Units Employee Housing(2700) Use Em to ee Nousin /Labor Cam A lication Form SITE MITIGATION Housing (2900) UNDERGRDUND IN]ECT10N CONTROL(3000) ❑ Environmental Assessmeite nt ❑ UST-CAP Site ❑ Local SiteH❑ RWQCB Cleanup nup Site ❑S to L! ❑ Water QuaEP Cleanuplity Remed at onlSite ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup RECREATIONAL HEALTH PROGRAM(3600)13 Pool [I Spa [3 Out of Service Pool/Spa ❑ Natural Bathing Area Number of Pools/Spas at Facility VECTOR CONTROL PROGRAM(4000) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical D Pp Notification Facility-Single ( ilt [:1 Body Art Facility-Sterilization (4121) ❑ Y � ent Colord (4130) ❑ Body Art-Temp Event Mobile ) LI 0 UID WASTE PROGRAM(4200) License# Capacity Vehicle# [I pumper Vehicle Registration# ❑ Package Treatment Plant El Chemical Toilets ----Number of Units [I Pumper Yard SOLID WASTE PROGRAM (4400) ❑ A !Cannery Waste Site ❑ Sludge/Ash Site ❑ Landfill ❑ Transfer Station g ❑ CIA Landfill Site ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility El Refuse Vehicles(#of units) ❑ Dumpsters> 20 cu yd (#or un;ts) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care LJ Acute Care ❑ Skilled Nursing Common❑ Large Generator C3Storage Facility ❑ 2- 0 small Generator 6a0or Limited0> 60 generator, ❑ Transfer Station ❑ Veterinary Clinic PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS =HD 46-Q2-003 Blue A !lcatlon Form W EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM C3G �. 3a 7- CONTACT PERSON 1 Day Ph .-] 7 SSC) Night Ph I 9 FEE ❑ Surcharge F E_� ❑ Other FEE PROGRAM ELEMENT 11 '17 ( ❑ Food Handier�� INSPECTOR# PERMIT VALID l� �- t0 Date �� r! INVOICE# vZ$ Check# AMOUNT PAID �D Date ACCOUNTING OFFICE Cash REVIEWED BY MASTERFILE RECORD INFORMATION PINK 48-02-034 1123113