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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED New EH Program at Existing Facility ❑New EH Pram rogand New Facility MAY - 6 2010 Facilit y ID D D,;2-Q3 O 57_ Program Record ID 4 6-3,157 2<3 SAN JOAQUIN COUNTY ONM Facility Address 710 -C . CALt i=ol�i �T_ s7'r-� �S zA� HbVM DE ART"Tn.AENT (Please Check the appropriate description and specify siz number or units and pertinent information) FOOD PROGRAM(1600) r�y 11 Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs,ev 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# Ohlobile Food Prep Unit-Make - Cq Vehicle Type cA--r*o?rivls- Color L4.)KCr-)F- Registration# )F-Registration# IGDICj032-�-3V .';oo94SLicense# '7310_S2_gE Sticker# is 53! ❑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(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(arms HOUSING PROGRAM(2400) ❑Hotel/Motel—Number of Units 11 Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee 11ousinglLabor Camp Applimdau Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) . 0 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. D NPIISEP Cleanup Site ❑UIC Site ❑ Abandoned I1W 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 17 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 ❑Proccss/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 D Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10—❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pll SFIfD 66-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON f/ Jo 4A- 2,111 Day Ph �fS6-Z��nf' Night Ph / PROGRAM ELEMENT L 1036 FEE 59:14il Oro ❑ Surcharge FEE ❑ Other FEE ' INSPECTOR# 3t{-7 PERMIT VALID 611 D to \2-1 -S ( I ID 11 Food Handler pry ❑ Check# AMOUNT PAID (q.3— Date _SQ10 '1O M- IWO10E# Ib Cash REVIEWED BY &. O (/3zI ACCOUNTING OFFICE Date