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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED ❑New HH PTyam at ExistingFacility ew EH Program andel New Fralcility JUL 19 2011 Facilif ID O�o� 13 ` Program Record ID 7 a53 1, SAN JOAQUIN COUNTY ENVIRONMENTAL Facility Address - HEAL Tti�]EPARTNIENT (Plcase Check the appropriate description and specify F11s,number of units and pertinent information.) FOOD PROGRAM( 1600) 11 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 Depwtnents ❑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 13 Special Event --Dates of operation from to ❑Produce Stand VAIIRY PROGRAM(20W) „ ❑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 Genmited Per Year ❑Recycle 1 Ezempt System(2299) ❑CRT Offsite Handlers(2216) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) ❑Permit-13y-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) ❑Hotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units )I nTloyee Housing(2700)Use EmDloye-HousifrC/Labor Camp ApPrUcation Form SITE MITIGATION(2900) 11NDERGROUND INJECTION CONII OL(3000) ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site_ ❑NPLISEP Cleanup Site ❑UIC Site ❑Abandoned IIW Site ❑non-NPLISEP Cleanup Site ❑P,%VQCB Cleanup Site -❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility 131.901 11Spa I]Out of Service Pool/Spat Natural Bathing Area VECTOR CONTROL.PROGRAM(4000) ❑ Poultry FarmMaximum number of birds [3 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(412 1) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) "QUtjD-WASTE:P_iOGRAM(4200)� b F-GZ5Io ��-Pum er Vehicl egistration#1 t"flp'T-9 G �3 License# # 100 Capacity � � Vehicle.# � umper Yard ❑Package Treatment Plant- MChemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludgc/Ash Site ❑Waste Tire Facility ©Compost Facility ❑ProcesslRecycle 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 13 Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-43 2-w ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EMD 46-42-003 Bluetippl_reafion Form EMERGENCY NOTIFICATION FOR THis FACILITY ANDIOR PROGRAM ��15 g�:/Y CONTACTPERS ! [[ Day P O C6 7a`� Nig V . PROGRAwt ELEm6e 'FEF, (7 a r� ❑ Surcharge FEF ❑ Other FIEF INSPECTOR# d S-- --_ PERMIT VALID . 1 t to L?J31 41 ❑ Food Handler k tash L43L"a AM U TPAID � fY311.DomDate ?11111I INVOICE,# d-{$'alt R£YiEWEIi'BY ��J AGCOVNFING OFFICE Date Macule Record Pink