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YSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> RECEIVED <br /> MASTERFILE RECORD INFORMA.TIO FORM JAN 13 2011 <br /> ❑New EH Program at Existing Facility blew EH Program and New Facility SAN JOAQUIN COUNTY <br /> Facilif �ID �o, 20 b 3 Pro ram Record ID 0 S 35 a D � ONMEN E 41 RDEPAR MEA IVT <br /> Facility Addr 77-7 3 �`3 <br /> (Please Check the appropriate description and specify size•number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Squarc 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-----MakeVehicle"i�pe-� Color <br /> Registration# +J�.� License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 11Temporary Food Facility—Dates of operation from to 13 lee Plant <br /> [� Special Event Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20110) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ~ CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility. ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By Ruin Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HotellMotel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Iamployee housing(2700)Use Employee Housin /Labor Camp Application Forth <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR%(3000) <br /> ❑Environmental Assessment 13UST-CAPSite ❑Local HW Cleanup Site. 13NPIJ'SEP Cleanup Site 13 UIC Site <br /> ❑Abandoned IItiV Site 13nod-NPLISEP Cleanup Site ❑R\VQCB Cleanup Site ❑Water Quality Remediation Site <br /> PtECREATIONAL HEAL'T'H PROGRAM(3600) <br /> Number of pools/Spas at Facility. ❑Pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br /> VECTOR-CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds 13 Kennel <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) C7 Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4 ��UiXS� a3 �j <br /> Pumper Vehicle Registratib� Iftcee#�7K 77 so2.3 Capacity �W :- X) Vehicle# <br /> : <br /> 13 Pumper Yard 13 Package Treatment Plant <br /> [I Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill 13 Transfer Station ❑Ag f Cannery Waste Site ❑ SludgelAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA•Landfell Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 eu yd---Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 13 Small Generator ❑Limited Ilauler <br /> ❑ Transfer Station ❑Veterinary Clinic y❑ Common Storage Facility--0 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTI=M PROGRAM(4600) Use PIVS EUD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION IFOS4HIS F=ACILITY ANDIOR PROGRAM <br /> CONTACT PERSON �C� g /�� /�'� Night Ph <br /> PROGRAM ELE;a�� <br /> FE © Surcharge FEE El Other FEE <br /> IIISPI>CfOR# PERMIT VALID \ \ j \ to V \ © Food handler <br /> check# \3 b*-k S U T PAID 1� 1 g' Date 13 f V, N-C- INVOICE# �D \b<9 <br /> j r i <br /> ❑ Cash REVIEWED AccouNTENG OFFICE (f'— Date � 13 <br />