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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM REC ❑ New EH Program at ExistingFacili ew EH Program and New Facili E►VE0 Facili ID 52 Program Record ID S 3 MAR 2 6 2019 Facility Address q- \ ('A S (,�, SAN JOAQUIN COUNTY (Please check the appropriate description and specify size,number of units and pertinent information.) HEATH LONIMENLgL FOOD PROGRAM(1600) LTH DEPARTMENT ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ g Commissary ❑ Dry storage only Kwith Food Preparation ❑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 Make Vehicle 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) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ------------❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility------------—-----❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-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 B forms 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) ❑ Tattooing (4121) ❑ 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(#of Unas) ❑ Dumpsters>20 cu yd (#or Units) ❑ 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 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph ,�RCA 30-CLVC4,Night Ph 2CLO vU Ole PROGRAM ELEMENT �y FEE DD ❑ Surcharge F E ❑ Other FEE INSPECTOR# /S /!5 PERMIT VALID t0 3D ❑ Food Handler Check it 1,3q-3 AMOUNT PAID Date 3 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07