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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existin Facility ❑New EH Program and New Facility �;E P FacilifID f"X� 00 [��53 Pro ram Record ID Q See� � 1 4 2007 �_ L SqN JOAQUIN COUNTY Facility Address (D 3.3 >C �/J� �'? SLP. �_ HEALTH DEMENTgL (Please Check the appropriate description and specify size,number of units and pertinent information.) PARTMENT FOOD PROGRAM(1600) , l Restaurant: Seating Capacity Square Footage _f/zx/)(,, Food Ilandlers Course required:. YE# No ❑ Commissary ❑ Dry storage only ❑with 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) IIAZARDOUS WASTE PROGRAM(2200) i ❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle I Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ 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.8 forms HOUSING PROGRAM(2400) ❑ notel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Employee IfousinZagbor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local BW Cleanup Site, ❑NPLfSEP Cleanup Site ❑UTC Site ❑ Abandoned 11W Site ❑non-NPLGEP 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(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 ❑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--13 2-10 ❑ 11-60-----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use P►f;SE11D 46-02-003 Blue Application Form EMERGEN Y NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON ml�-_ Day Ph j°l 42V?-: 01-'Night Ph( �;;/ C Zn PROGRAM ELLLE,,NIIE�INT FE � 11 Surcharge FEE 1:1 Other FEE INSPECTOR# V�'l PERMIT VALID ,� O to ` �3'U U 11 Food handler Check# 2 y S 11N10UNT PAID Ddte `1�\w 07�_ INVOICE# (o(o Z ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date :L17107