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F-';`jO"-Qu" MA,T,.L. <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT <br /> RECEIVED <br /> RECORD INFORMATION FORM MAR 2 9 2011 <br /> ❑New EH Program <br /> at Existing Facility T1Ncwr EHPregrarnand New Faellrty� SAN JOAQUIN COUNTY <br /> Facilit•ID f t C,C �C l Pro ram Record ID r-ti,S, f ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Facility Address ?(Z & <br /> (Please heck the appropriate description and specify sing number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel 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—Dates of operation from to ❑ Ice Plant _ <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) - <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator--Totts 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 /> ❑HoteUMotel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employ=IIousing(2700)Use Employee ffarrs(ne/Labor Camp Amlft ion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Ppol ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) -MF5�d7lfet' Liycense# capacity�1umperVehicle—Registration#/FZ - <br /> Vehicle-#� <br /> ❑ Package Treatment Plant ❑ Chemical Toilets— umber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash 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 ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ SkilledNursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PHS EMP 46-01-003 Blue Appliearion Forrn S CELL <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM .(. <br /> CONTACTPERSON yy,��,, a Day Ph S/%) Sd$�S���Night Ph Jt SlD'2i4-r-SoS <br /> PROGRAMELEMENr*PO) 14�K� FEEa1 ❑ Surcharge FEE [I Other FEE <br /> INSPECTOR# 515PyN PERMITVALID . 2�t 11 to 3 [I rood Handler <br /> P,Chccka J.] r� AMOUNT PAID ��D -�Date 3 �- ! / INvoICE# '2'x5:2-JO <br /> ❑ Cash REviFwEDBy ACCOUNTINGOFFICE (, Date 3 �-Y/// <br /> Mactr file Record Pink <br />