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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED ❑ New EH Program at Existing Facility ❑New EH Program and New Facility JUN 2 1 2012 Facility ID C d2 I O Program Record ID Fpflc 57T -24-1 IRONM SOAL ' UNTY ENIIRONMEHTAL Facility Address 0,ovf G/4 "EAST DEPARTMENT (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ 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 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 Stand DAIRY PROGRAM (2000) ❑ 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) ❑ CRT Offsite Handlers(2218) ------------❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility -------------------11 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 USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION 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 PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4122) LI UID WASTE PROGRAM(4200) oo37'r /4,t5?7 Pumper Vehicle Registration#I rV!JF70-�84vA License# Capacity 's Vehicle# Pumper 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 w of units) ❑ Dumpsters>20 cu yd I#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1L dr5 ,Day Ph �//6_ 776��0�' Night Ph .S 7n -& PROGRAM ELEMENT FEE l"" Surcharge FEE ❑ Other FEE INSPECTOR PERMIT VALID a) 12 t0 12-101110Food Handler�7 Ix Check# Ill1f' AMOUNT P*D IO •� Date 1.7 ;21 1 INVOICE##/ 11 Cash REVIEWED BY ACCOUNTING OFFICE Date t0 7� 48-02-031 MASTERFILE RECORD INFORMATION PINK 11/15/07