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r- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> NASTERFILE RECORD INFORMATION FORM RECEIVED <br /> ❑New Ell Prograrn at Existing Facilityew EH Pro and New Facility JUL 19 2011 <br /> Facilit ID D D :qa <br /> Program Record ID �� SAN JOACQUIN COUNTY <br /> ENVIRONMENTAL <br /> Facility Address ;;:z-;?-) HEALTH DEPARTMENT <br /> (Please,Check the appropriate descrlption and specify s,ize,number of units and ertineat information.) <br /> FOOD PROGRAM(160D) <br /> D Restaurant. Stating Capacity Square Footage Food Handlers Course required. YES D No ❑ <br /> O CommissaryO Dry storage only D with Food Preparation 0vending Machines Number of Units <br /> D Retail Market---Square footage ©with Meat Market only D Multiple Departments D Prepackaged Goods Only <br /> D Mobile Food Vehicle----Kake Vehicle Type Color <br /> Registration# License# Sticker# <br /> D Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> O Temporary Food Facility----Dates of operation from to D Ice Plant <br /> D Special Event --Dates of operation from to 0,Produce Stand <br /> DAIRY PROGRAM(20W) <br /> 0 Grade A Dairy ©Grade B Dairy D Milk-Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA D State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM k2200)' i <br />' ❑Hazardous Waste Generator. Tons Generated Per Year '13 Recycle I Exempt System:(2299) <br /> I D CRT Offsite Handlers(221 B) D Silver Only(2222) D Appliance Recyclers(2217) <br /> Tiered Permitting Facility----- D Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> D Permitt By-Rule Fixed Unit L7 Permit By-Rule Household Hazardous Waste <br /> D ABOVEGROUND STORAGE TANK FACII.rI'Y(AST)(2398) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and B Arms <br /> HOUSING PROGRAM(2400) <br /> D Hotei/Motel Number of Units .D Jail or Exempt Institution Number of Units <br /> employeeHousiag(2700)Use.Employee Housingffig Cd►ttp Apyliaatiaa Form <br /> SITE MITIGATION(2900) ' - UNDERGROUND INJECTION CONTROL( 000) <br /> .©Environmental Assessment D UST-CAP Site D Local HW Cleanup Site. D NPLISEP Cleanup Site !]UIC Site <br /> D Abandoned HW Site D noa NPLISEP Cleanup Site D RWQCB Cleanup Site D Water Quality Remediation Site <br /> Rr=cRt&nONAL HEALTH PROGRAM(3600) <br /> Number of PoolslSpas at Facility,. D P9o1 D Spa P Out of Service Pool/Spa ❑Natural Bathing Area <br /> b <br /> VECTOR CONTROL PROGRAM(4000) <br /> ©Poultry Farm Maximum number of birds Kenna <br /> TATTOO,DoDy PItGRCING PERMANENT COSMETIC PROGRAM(4100) <br /> D Tattooing(4121) ❑Body Piercing(4120) D Permanent Cosmetics(4122) <br /> LtQUIa WASTE PROGRAM(4200) <br /> Stax <br /> �pYhicleRegistration# t'n�'� 6 P 3Licese# J l�D Capacity c7 Vehicle#mper Yard D Package Treatment Plant i tchemical Toilets Number of Units <br /> PROGRAM(4400) <br /> D Landfill ❑Transfer Station D Ag l Cannery Waste Site D Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility D Process/Recycle Facility D CIA,Landfill Site <br /> D Refuse Vehicles Number of Units D Dumpsfers>20 cu yd--Number of Units El Firm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> D Primary Circ D Acute Care D Skilled Nursing I]Large Generator I] Small Generator DLimited Hauler <br /> O Transfer Station '0 Veterinary Clinic D Common Storage Facility-----0 2-10 D 11.60----D>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Mae Application Form <br /> EMERGENCY NOTIrecATION roft r is FACILITY ANDIOR PROGRAM 2 0 <br /> CONTACT PERS s_ Day P D CL 70 r Nig S/ s <br /> PROGRAM ET,EMEPi' # O Surcharge FEE'.% El Other FEE <br /> INSPECTOR# O PERMIT VALID . T I i to i?�3 f � _ ❑Food Handler_ <br /> Checks L-43Ams v T PAID r� 9_C� Date I � INVOICE# <br /> Cash REVIEWED BY S5�i�CCOUNTING OFFICE Date 7 l f <br />