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r I USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD'INFORMATION FORM PAYMENT r New M Program at Existin Facility ❑New Ell Program and New Facility RECEIVED �Facilif ID 7i to ` Program Record ID O S 3 o s u AUG 2 1 20og FacilityAddress O HENVIROONME,,T.ANT' H�fr OEC {Please Check the appropriate description and specify size,number of units and pertinent information.) �1 MEAT FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course reequired:. Y>ws❑ 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 Staud DAIRY PROGRAM(2040) ❑ Grade A Dairy ❑Grade B Dairy, ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) ' ILAZARDOUS WASTE PROGRAM(2200) i ❑hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Reeyclers(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) ❑HatellMotei Number of Units .❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use F.m to ee flousin !Gabor Camp Aprfica6otr Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) ©Environmental Assessment ❑UST-CAP Site ❑Local IDV Cleanup Site. ❑NPLISEP Cieaoup Site ❑UIC Site ❑Abandoned II3V Site ❑non-NPLISEP Cleanup Site ❑RNVQCB Cleanup Site ❑Water Quality Remediation Site t RECREATIONAL HEALTH PROGRAM(3600) Number of PoolslSpas at Facility. ❑Pool ❑Spa ❑Out of Service Pooltspa 0 Natural Bathing Area VECTOR.CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING,PIERMANE14T COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑Permanent Cosmetics(4122) QUI 1)WASTE PROGRAM(4200) i� / n 'W Pumper Vehicle—Registration# X70 U Q License if t7 Capacity-- Vehicle# 11 PumperYard ElPackage Treatment Plant- 11Chemical 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 ❑Dumpsiers>20 cu yd Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM{(4500) ❑ Primary Care ❑Acute Care ❑ S1d11edNursing ❑Large Generator C7 Small Generator ❑ Limited Mauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—Z] 2-10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use FIES F.HD 46-02-003 Blue AaEficatiort Form EMERGENcy NOTirICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1/\ Day Ph " OvG Night Ph PROGRAh'lELn%IF-ti'T 2 FEE i S�O ❑ Surcharge FEE ❑ Other FEE INSPECTOR# S PERMIT VALID . `02 t to 9,1 3 , 0 9 ❑ Food Handler V, Check# AMOUNT PAID . O O Date 12—q4 INVOICE# ❑ Cash R.Evir;wFD'BX ACCOUNTING OFFICE Date 9,1 ILA "