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PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD'INIi ORMATION FORM J U N Q 1 2007 ❑New EH Pro am at Existing Facility ew E,H Program and New Facility Facilitj ID �� LF Fro ram Record ID SAN JOAQUIN COUNTY ENVIRONMENTAL Facility Address W• 6,44�7` 4G HEALTH DEPARTMENT (Please heck the appropriate description and specify s,!M number of units and pertinent information.) FOOD PROGRAM(1604) ❑Restaurant: Seating Capacity Square Footage Food handlers Course rewired:. Yrs❑ No ❑ ❑ Commissary [l Dry storage only ❑with Food Preparation El Vending Machines Number of Units ❑ Retail Market-----Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit--Maltz Veliicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) 0 Grade A Dairy ❑Grade B Dairy ❑Milk Mpenser Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyolers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permitt By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and BJorms HOUSING PROGRAM(2400) ❑ HoteUM.otel Number of Units ❑Jail or Exempt Institution Number of Units Employee Ilousiag(27 00)Use m to yei Housln /Labor Cam p A Ucation Form SITE MITIGATION(2900) UNDERGROUND INJECTION C014TROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site. ❑NPLfSEP Cleanup Site ❑UIC Site ❑ Abandoned HW Site ❑noQ NPIJSEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site RECREATIONAL,HEALTH PROGRAM(3600) Number of PooWSpas at Facility ❑P901 ❑Spa Out of Service Pool/Spa ❑Natural Bathiag Area VECTOR COHTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIE=RCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑Pumper Vehicle-Registration# License# Capacity Vehicle# ❑Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles Number of Units ❑Dumpsters>20'cu yd—Number of Units ❑Firm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ' ❑Acute Care ❑ Skilled'Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS EHD 46-02-003 Blue Application Form Ek1ERGFNCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON b'-c 11w54- Day Ph *C-1--7 L('>-/ Night Ph PROGRAMELFMIrWT I(I- FEE l SD ' (r)) ❑ SurchargeFEE % ❑ Other FEE 1N,SPEC OR# 1�fy1�` _4 PERMIT VALID ��010 I to 3 t[OT 11 Food Handler LYJ Check# i -[�Z AMOUNT PAID I,t• IID Date (Off 107 INVOICE# 16'NO-6-1 &Cash REv1EwEuiBr Q?j ACCOUNTING OFFICE Date (,f 1 I 0