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J l PAYMENT `SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM JUL 2 1 2011 ❑New EN Program at Existing Facility XNew Ell Program and New Facility SAN JOAQUIN COUNTY . ENVIRONMENTAL Facility ID leA, DO ER o-;1_1 Pro rant Record ID S3 (o HEALTH DEPARTMENT Facility Address %3P So (1,46 - g-01 ✓+ (Please Check the appropriate description and specify siz number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquarc 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 r Color�� Registration fllAI906"censc# LIQ'' D Sticker# L2�-t•Z7 ❑ 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-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) t ❑ Hazardous Waste Generator--Tons Generated Per Year -❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Pemait-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 U,ST A and B forms HOUSING PROGRAM(2400) _ ❑Hotel/Motel—Number of Units .❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee 7fousineQabor Camp Applieaeion Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPUSEP Cleanup Site ❑UIC Site ❑ Abandoned 11W Site ❑non-NPI/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 ❑ CIALandfill Site ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Raoch 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 URLIC TER SYSTEM PROGRAM(4600) Use PIIS FfID 46-02-003 Blac Applicarion Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM r TACTPERSO Day Ph 2o9-�a,3aj- 3 7 9 9 Night Ph Za lC' Y6 Q - 3 y 7RAMELEhIENT �tP FEE (`� -� ❑ Surcha ge FE ❑ Other FEE CTOR# 33(4 - PERMITVALI oft toVA 1 11 ❑ Food Handler eck# AMOUNT P9AIU Date •LINVOICE# ar83tfy ❑ Cash REVIEWEDBY L �J ACCOUNTING OFFICE Date 7jLj •+ +• Maae,file Record Pink