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SAN JOAQUIN COUNT" ENVIRONMENTAL HEALTH DIV ON PAYMENT MASTERFILE RE, RD INFORMATION FO EH 00 69 � RECEIVED ❑New EH Program at Existing Facili cw EH Pro mm and New FacilityDEL+ _ 9 X103 i= Facility ID 0 0 Pro ram Record ID522-( ��r� OAOUIN COUNTY Facility Address ayy0 S 4 KL` \�-PbW�i�J JrC O1 1 G� ��J HONMEDEPARTMENTAL size, (Please Check the appropriate description and specify 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 VehicIcTypc Color Registration# License# Sticker# Mobile Food Prep Unit--Make GUEJ`I Vehicle Type Color Registration#\G( C1�+1�L�'0. \7Lt gq3 License# �yy0� Sticker# - Kbql? ❑ 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 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 8 ford=s 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--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-----02- 10-------❑ 11 -60------1:1>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Bete Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONDay Ph Night Ph PROGRAM ELEMENT \U2-'b FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# W-k3 PERMIT VALID I i1 R(03 to 1y/31(o -4/-0 Food Handler ❑ Check# AMOUNTPAID I�-� Date (y(gX03 2,X-INVOICE# ash REVIEWED BY ACCOUNTING OFFICE Date O EH 0069 Pink Form Rev.02/25/03