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SAi►N, JOAQUIN COUNTY E . ONMENTA.L HEALTH DEPAR*ENT PAYMENT NT R CORD INFORMATION FORM RECEIVED �New EH Program at Existing Facility ❑New EH Program and New Facility Arm 3 0 .2009 Fa�ID S L'0/4'-'/'7 Program Record ID ,;AN JOAQUIN COUNTY Facility Address NTAL l6 Y6/ �� - ,(,� kms„ 400V r �`3� A"1�+',ROEOAR1in NT (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 ❑ ❑'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 -0-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 CUP A ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) CI 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-8y-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 USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-----Number of Units Employee Rousing(2700)Use Employee Nousinp/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-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(4 100) ❑ 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 XAg/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----❑ 2- 10------- ❑ 111-60------0 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EfID 46-02-003 BlueApplieation Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 4Vd d FEE 0-0 ❑ Surcharge FEE ❑ Other FEE INSQrCTOR# WX0 PERMIT VALID /.?t)In t-_V3lD�_ ❑ Food Handler e� kash heck# `D Z-7& O D AMOUNT PAID (® eS(7 Date � Q 'INVOICE REVIEWED BY 41S ACCOUNTING OFFICE Date 34 'p 48-02-034 10/6/2003 Masterfile Record Pink °