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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM PAYMENT <br /> RECENED <br /> ❑New EH program at Existing Facility Rkew EH Proam and New Facility <br /> Facili!y ID ) . ��'C 'i L Program Record IDNOV 3 0 2011 <br /> Facility AddreSs -- -+- : f,. _ t, r t_ % H�ni'"i�r'o'parr <br /> Please Check the ate descri tion and if stz number of units and pertinent informl ion.{ <br /> � PPI'olm F specify� P - <br /> FOOD PitOG M(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:- Yrs❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Areuding Machines Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility---Rates of operation from to ❑ lee Plant <br /> ❑ Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy CI Milk Dispenser Numbcr of Containers in Multi-Head Unit <br /> GUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) $ <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/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-Rule 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 /> Employee Housing(2700)Use F•mpleyee'I{Ouslne/Labor CamjZ AwUcation Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ EvAroamental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑U)iC Site <br /> ❑Abandoned HW Site ❑non-NPLISEP Cleanup Site C7 RWQCB Cleanup Site J❑Water Quality Remediation Site <br /> RECRIEA'"ONAL HEALTH PROGRAM(3600) <br /> Number of PooWpas at Facility ❑P991 ❑Spa ❑Out of Service PooilSpa ❑Natural Bathing Area <br /> VECTOR.CONTROL PROGRAM(4000) <br /> ❑Poultry Farm number of birds ❑Kennel <br /> TATTOO 13ODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) 0 Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> RC 1;Pumper Vehicle Registration# (°F Z l6 i lh L License,# Capacity 2-2 Cites Vehicle <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ask Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑CIA landfill Site <br /> ❑Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Fariu/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-H) ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS ER-D46-02-1143 Bluertpplicadon Form <br /> F-MERGENCY NOTIFICATION FOR Tmis FACILITY ANDIOR PROGRAM <br /> CONTACT PERSONc�'� y C�t--) Day Ph ���- a � �t' Night Ph <br /> M <br /> PROGRAELEMENT- �-T Z _ FEE I�,4 7L- ❑ Surcharge FEE ❑ Other FEE <br /> INSPWTOR# ��f�f PERMIT VALID to ❑Food Handler <br /> lr�,Check# =�1�. �- AMOUNT PAID [ c'. �.' Date 1 I j j t i INVOICE# L 7- <br /> ❑ Cash REviEWED BY Accoui TING OFFICE �;: ( .. Date <br /> Mncte>-fiIc Record Pink <br />