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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED n ❑ New EH Program at Existing Facility ❑New EH Program and New Facility JAN ' S 2U09 Facilit ID 0 D(9y S a Program Record ID Q-0579 !1 SAN JOAQUIN COUNTY ,-Facility Address HEALTH ENVIRONMENTAL (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) TlE� VCAA::0Q" ❑ 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 ------------------❑ 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 Housing/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 HW Site ❑ non-NPL/SEP 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) ❑ Pumper Vehicle 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 ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#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 INSPECTOR NTACT PERSON ` 'tAG-- `� S Day Ph 2c j_.72-7_._/SL? Night Ph 2.O�% 3Z7•/S-.S OGRAM:ELEMENT FEE ❑ Surchar a FEE ❑ Other FEE �?�{�i PERMIT VALID t0 �— ❑ Food Handler (� Check# AMOUN PAID 4c t60 Date ( INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE — Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07