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PAYMENT. RECEIVED SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DEPAR ENT JUL 2 7 2009 MASTERFILE RECORD INFORMATION FORM SAN JOAQUIN COUNTY 11 New EH Pro ram at ExistingFacili vi N NrAL ew EH Program and New Facil' � 4a41,_-�"Program Record ID {�5 (� 3 2 X 459�v' a� h_ _V ; Facility Address_9 LuFsriN ; o, vro,lr_�9 OV (Please check the appropriate description and specify size. um r f unite and pertinent Info on.) f, FOOD PROGRAM(1600) ; ❑Restaurant: Seating Capacity Square Footage Food Handlers Course re aired; 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 ❑ Mobile Food Vehicle–Make Vehicle Type Color Registration# License# ;+ r Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Calor x. Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to, ❑ Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2404) © Grade A Dairy ❑Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) 3 ❑ 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 i UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms HOUSING PROGRAM(2.400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt institution---Number of Units • Employee Housing(2700) Use Employee Housin bor Como Awlicadon Form SITE MITIGATION(2900) UNDERGROUND INJECTIO!d CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH FROG (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa w ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL,PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds - [I Kennel a TATT00,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) i ID WA TE PR GRAM(4200) 77'A�I�/z# /Yyr��5,umper VehicieRegistration# License# ges_54a" Capacity Z�`" Vehicle# ) f umper 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(#of units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site + MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Haulef -# ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 1111 -60 © >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PM EHD 46-02-003 Bfue ADDlicadon Form - _ EMERGENCY NOTIFICATION FOR THIS FACILITY ANDloR PROGRAM CONTACT PERSON /& Day Ph ZjZZQ2,5 .7 Night Ph94 -437.Z PROGRAM ELEMENT 42—cfLi FEE V 1-5-t9.d17 ❑ Surcharge FEE ❑ Other FEE INSPECTOR Ip PERMIT VALID In 0I_ to ❑ Food Handier Check# `u 2 AMOUNT PAID - S V Date "1 ?r1 0`l INVOICE# I��4 1p t-( ❑ Cash REVIEWED BY {� ©2jZ ACCOUNTING OFFICE Date L ? .6 r 48-02"034 S 11/15107 , [ d MASTERFILE RECORD INFORMATION PINK -