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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM PAYMENT ❑New EH Progain aat Existing,Facility - ❑New EH Program and New Facility -CEIVED Facility ID LgR U O 7 i3 ` Pro ram Record ID &o s-3/t7 D 2-- FEB - 8 2011 'Q S C[�tt-4��Fiw�!j-1�1 I S}JL IGfdyJ C..f)� `7 ir2 O 3 'OAQUIN COUNTY Facility Address C1 NIRONMENTAL (Please Check the appropriate description and specify s�number of units and pertinent information.) _ rti DEPARTMENT FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare 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 Mobile Food Vehicle---Make �S I7 Vehicle Type 2^ Color l 9Vl f I'C Registration# License# i ' Sticker# 4 3R 3 ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility--,Dates of operation from - to ❑ Ice Plant [3 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)- t ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Ezempt System(2299) ❑ CRT Offsite Handlers(221 g) ❑ 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/Motcl—Number of Units .❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Fmpfovee%Lousiae/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION C2NTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned MY Site ❑non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) - - Number of Pools/Spas at Facility. ❑ P901 ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) El Poultry Farm—Maximum numb erofbirds 11 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/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator lQ Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-16—1111-60—❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PN'SBIID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR Tins FACILITY AND/OR PROGRAM CONTACT'PERSON-1�"`^�.4I owv��4.Z'' 11 Day Ph 20`I q b OIG I Night Ph �-O 5 I�I PROGRAM ELEMENT 1 3 FEE `YS — ❑ Surcharge FEE'- 11 Other FEE INSPECTOR# //��2$too� PERMIT VALID . 2. to X2—( 3\ / 1�/�� ❑Food Handler l Check# CQ 1 —1 —1 AMOUNT P ID \ (N Date k lq`s INVOICE# r/1419 0 ❑ Cash RFvuwED BY Y ACCOUNTING OFFICE Date 6 L`