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• PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM APR 19 2012 Lit. EH Program atExistin Facility ❑New EH Pro , and New Facility &"MR�n tU ccu�-r n C Z� Zo -7 HE^- eea �rererrr PFaci iit 'ID �N �� ,��`7� Program Record ID Facility Address E C A3 _ Y1 (Please Check the appropriate description and specify size,nu ber of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No l�C ❑ Commissary ❑ Dry storage only ❑with Food Preparation 11 Vending Machines—Number of Units ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged G ods Only Mobile Food Vehicle--Make C Vehicle Type -2)-,2— \J i�( c- Registration# ��h 5,� License# Z u� `b��`/ Sticker# _I{ ❑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) ❑ Hazardous Waste Generator---- Tons Generated Per Year ❑Recycle f 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 forms HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units .11 Jail or Exempt Institution Number of Units Employee housing(2700)Use Fniployee Ilousing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑RNVQCB 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(4 120) ❑ 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 ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60-------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS EfID 4642-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON �t Day Ph 4776 - '5�'3:�LZ Night Ph o G' PROGRAM ELEME 'T FEE ❑ Surcharge FEE El Other FEE INSPECTOR# PERMIT VALID . to M3 t ❑ Food Handler G Vt`7 1 (2-- INVOICE# El Check# AMOUNT PAID Date ❑ Cash REVIEWED BY CI `/ ACCOUNTING OFFICE Date S ?.-- M—t—file Re.cnni Pink