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SAN JOAQUIN COUNTY ENVIRONMENTAL IiEALTII DEPARTMENT PAYMENT <br /> RECEIVED <br /> MASTERFILE RECORD INFORMATION FORM MR 2 9 2011 <br /> ❑New EH Pro am at Existing Facility &New EH Program and New Facility <br /> i SAN JOAQUIN COUNTY <br /> Facility ID O C a o'-7 S3 Program Record ID 3 �,/ L HFENVIRO ALTH[DEPARTMENT <br /> ENTAL <br /> Facility Address G `5.2 <br /> (Please Check the appropriate description and specify siz number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending 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—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)- d <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facality ❑ 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 /> ❑HoteUMotd—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Ltnploree Ifousine/Labor Camp Applk-aden Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑ non-NPIJSEP Cleanup Site ❑RN'QCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Poot ❑ 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) - <br /> ❑ Pum er e—RegistratioD# License# Capacity Vehicle It _ <br /> umper Yardj ❑ Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SO STE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag I CanneryWaste Site ❑ SludgelAsh Site <br /> ❑Waste lire Facility ❑ Compost Facility ❑ Process/RecycleFacility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—.[] 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS LIED 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON // 11-11 A y h <br /> DaPh `7�- b � 26 Night P <br /> PROGRAMELEMENT 7 K y FEE ❑ Surcharge FEE ❑ Other FEE <br /> I�N(SPECTOR# PERMIT VALID 3IJ-Q I G 1 to 1 2;(31�[l ❑Food Ifandler <br /> I�rCheck# AMOUNT PAID 1 0 -� l� Date INVOICE# <br /> ❑ Cash REVIEWED BY AccouNTING OFFICE Date <br /> ,,, „„ Maatfile Record Pink <br />