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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT. MASTERFILE RECORD INFORMATION FORM RECEIVED ❑ New EH Program at Existing Facility ew EH Program and New Facility �Itil�MAR Facility ID Program Record ID SANz 2��9 JOAQUIN NTAL Facility Address � �s�6 ENIFlRONMETAL (Please check the appropriate description and specify-i- number f units and pertinent information.) HEALTH DEPARTMENT FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units [I Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to E]WA�I 1:1Produce Stand 11 Special Event---Dates of operation from to CFO B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) ❑ 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) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Sin_We Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body A i,7r Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) lECE�yED ❑ Pumper Vehicle Registration# License# Capacity R Vehicle# El Pumper Yard I-] PackageTreatment Plant 11 Chemical Toilets--- e��OQ SOLID WASTE PROGRAM (4400) M �T( [3 Landfill Transfer Station Ag/Cannery Waste Site SM Opal sh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility EPMX-movIl Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters>20 cu yd (#of Units) tHEA3-T t Farm/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 PWS EHD 46-02-003 Blue Application Form EMERGEN Y NOTIFIC TION FOR THIS FACILITY AND/OR PROGRAM �p r CONTACT PERSON Day Ph2va -,q.23- Night Ph PROGRAM ELEMENT FEE 5 Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID / t0 � , El Food Handler Check# 13MOUNT PAID`;'/ Q2i1 ate `�/ 2—/j I INVOICE# lb Cash EVIEWED BY l.G[ / ACCOU TING OFFICE Date 48-02-034 ' MASTERFILE RECORD INFORMATION PINK 1/23/13