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Amok SAN JOAQUIN COUNTY ENMONMENTAL HEALTH DEPARTi..,,:NT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED New EH Pro am at Existing Facili ❑New EH Pro am and /New Facili 1 2 2005 Facilit ID F-VUO 1 to S' Program Record ID SAN JOAQUIN COUNTY Facility Address -7 -;�&-' : , C',)4 C 4414 ENVIRONMENTAL HEALTH DEPARTMENT (Please Check the appropriate description and specify size•number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ NO ClCommissary ❑ Dry storage only 11with Food Preparation ❑Vending Machines-Number of Units // ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make W Ec c.-S Vehicle Type -1_"<<--=d— Color Registration# / w c. 2-v0 C-2-7 y License# t G CL-i 2 y Sticker# C� 2 D 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 COPA ❑ 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 HousinvLabor 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-NPL/SEP 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--Number of Units ❑ Dumpsters>20 cu yd----Number of Units Cl Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic Cl Common Storage Facility-----02- 10-------011 -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 /'4/ti-1 C E c-4 6-_(_T-,d�4Z4tL Day Ph Z _-2q1iZ Night Ph PROGRAM ELEMENT 3�S FEE ( '17'U • (A) ❑ Surcharge FEE ❑ Other FEE INSPECTOR# -7 � PERMIT VALID_b1\21 0 S to 101 3 1 p ❑ Food Handler ❑ Check# AMOUNT PAID , S 0 0 D Date t l)1 \2 1 U S INVOICE# L/ Cash REVIEWED BY Cq-& C`) ACCOUNTING OFFICE Date o 48-02-034 Masterfile Record Pink 10/6/2003