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SAN JOAQUIN COUNTY ENVIRONTNIENTAL IiEALTI-I DEPARTMENT PAYMENT NIASTERFILE RECORD INFORMATION FOIU�I RECEIVED New EH Program al Existing Facility ❑New EH Program and New Facility APR 15 2011 Facilit •ID 0 0��o ( Prgram Record ID 1'-vSJ L Z� 6AN JOAOUA COUNTY ENVIRONMENTAL Facility Address j7(-7 10AJ Gl---�� e9S --Q,(o HEALTH DEPARTMENT (Please Check the appropriate description and specify size•number of units and pertinent information-) FOOD PROGRAM(1600) ❑ Restaurant Scating Capacity Square Footage Food Handlers Course required:. YEs l< No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Markel--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vchicle---Make Vehicle Type Color Registration# License# Sticker# P(Mobile Food Prep Unit—Make VeliicleType C,4TEGrNC-s Color- Registration# 164A-IIS 4z3 715 t�o1 License# t4LE.R t&-7 Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice I'lanl ❑ Special Event —Dates of operation from to ❑ Produce Slaud DAIRY PROGRAM (2000) _ - ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Numbcr of Containers in Multi-Bead Unit COPA ❑ Stale Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) j ❑ Hazardous Waste Generator-----Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2216) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Pemrit-By-Rule Fixed Unit ❑ Pernut-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(amts HOUSING PROGRAM(2400) - ❑ HotcItMotel--Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Employee IfousinglT abor Camp Application Fonn SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) -❑ Environmental Assessment ❑UST-CAI'Site ❑ Local 11W Cleanup Site, ❑ NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned 11W Site ❑ non-NPLISEP Cleanup Site 11 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(412 1) ❑ 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,Landfrll 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 PHSE11D 46-01-003 Iliac Applica(iort Form EMERGENCY-bTITIGAT.I ON EOR TNIs FACILITY AND/OR PROGRAM CbF � CONTACT CERSON ,�OS [-r rJ,'� Day Ph_C-2_tXi )4D$-1(8.3 Night Pll PROGRAM ELEMENT I(03s FEE--ff�2_U3 0--D ❑ Surcharge FEF - ❑ Other FEF, INSPECTOR# % i0 P6RMITVALID . 4 07 1) to 1'2-13I111 ❑ Food Handler ❑ Check# AMOUNT PAID 2 -� 03. C)C) Date Lfj/� f( INVOICE# :2 Slk23 Cash RLv1EwED BY c7vo9�fr/I ACCOUNTING OFFICE Date ) Vi I ._—I Masi Ie Record Pink