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SAN JOAQUIN COUNTY ENVIRONMENTAL IiEALTII DEPARTMENT MASTERFILE RECORD INFORMATION FORM PAYMENT RECEIVED New EH Program at Existing Facility ❑New EH Program and New Facility JUL 2 7 2011 Facilit ID 0 O gs r�tr�aamR Record ID P--X) 53 S-1 2. - SAN JOAOUIN COUNTY Facility Address 3{SSO ENTDEARTEEALH DEPARTMENT (Please Check the appropriate description and specify s_e number of units and Pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ 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 i ❑ 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-Ilead Unit CUPA ❑ Slate Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) j ❑ Hazardous Waste Generator---Tons Generated Per Year -❑ Recycle f Exempt System(2299) ❑ CRT Offsite Handlers(22is) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑ 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 UST A and B forms HOUSING PROGRAM(2400) - ❑Hotel/Motel—Number of Units .❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee%fousine/Labor Camp Application Form - SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IIW Site ❑ non-NPIJSEP 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) LIQUID WASTE PROGRAM(4200) - ❑ PumperVehicle-Registration# License Capacity 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 ❑ CIALandfill 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 ❑ Small Generator ❑ Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---❑ 2-10—❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PN'SFITP 46-02-003 Bene Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON �7_LLOIA-rJA 403.7-5 Day Ph 4{O/-63Y- Night Ph PROGRADIELEMENT FEE 4 If07) ❑ Surchar eFEE El Other FEE INSPECTOR# PERMIT VALID to 3ttIcJrood Ilandler ❑ Check# AMOUNT PAID fC . © D Date //INVOICE# --719-7495 -Cash REvrewEDBY (3-0 023 ACCOUNTING OFFICE .. .11 Maztefile Record Pink