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SAN JOAQUIN COUNTY 1WRONMENTAL HEALTH DIVI N PAYMENT <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) RECEIVED <br /> ❑New EH Pro rant at Existing Facility ❑New EH Pro ram and New Facility <br /> � <br /> ��Facilit ID �" 7� O P�r�o gram Record ID SA s23 -7 � 2W2 <br /> Facility Address 3Vz N ? p' aXo PUBLISAN C HEALTH ERNCES <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) ENVIRONMENTAL HEALTH DIVISION <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare 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 /> ❑ Mobile 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-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) - <br /> ❑Hazardous Waste Generator-----------------------Tons Generated Per Year <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)­Numberof AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) , <br /> ❑ Iiotel/Motel-----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Bousing(2700) Use Employee Housine/Labar Canrn Application Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ U1C Site <br /> Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vchicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-----Numbcr of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery WastcSite ❑ Sludge/Asli 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/Ranch 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----EI 2- 10-=-----❑ 11 -60'------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT_e12 .�Q FEE Surcharge FEE ❑ Other FEE <br /> InsrecToa# PERMITVALID-�— to _ ❑ Food Handler <br /> Check p AMOUNT PAID Date INVOICE# Oa93 8/D <br /> 71 Cash REVIEWED BY ACCOUNTING OFFICE Date .3(p/OL- <br />