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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT pAYMENT <br /> MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> ❑New Ell Program at Existing Facility ❑New E-11 Program and Nei),Facility2 g 2007 <br /> Facilit ,ID o Program Record ID OCT <br /> SAN JOA©UIN COUNTY <br /> acility Address ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> (Please Check the appropriate description and specify s•ue•number of units and pertinent information.) <br /> I"OOD PROGRAM(1600) <br /> Xi_estaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market--Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Alobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) I <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-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 /> ❑ Ilotenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use F,mploree flousingl abor Caren Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local IfW Cleanup Site, ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW Site 13non-NPUSEP Cleanup Site ❑RIVQCB Cleanup Sitre ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(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 ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑Dumpsters>20 cu yd--Number of Units ❑ Farm/Rauch 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--D 2- 10 ❑ 11 -60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIFSFlfn 46-02-003 blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> i CONTACT PERSON M \V- ` I Day PhNight Ph 2-C t 1- <br /> PROGRAM ELFhIENT b V FEE 1 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# b PERMIT VALID Z`l 0 toy 0 J 3( ' 0 Q ❑ Food handler�7 <br /> Check# , 3 AmOUNTPAID as o- Date l� Z� O� rvzs- INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />