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PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED "TERFILE RECORD INFORMATION FORM AUG -8 2011 ew EH Program at Existing Facility ❑New EH Program and New Facility SANJOAQUIN COUNTY ENVIRONMFacilit ID 001 -7q� `< NTAL Pro ram Record ID /)^� �� HEALTH DEPARTMENT Facility Address58' E CA-K 12-7k (Please Check the appropriate description and specify see numbet of units and pertineut information) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines-Number ofUnits ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments qQrepackaged Goods thily i 'FMobileFood Vehicle--Make C/li�4il_! _ Vehicle Type 137 V Color 1 �ut,"(•_fi/„i Registration#)UCElT i i W 7 V«C29b(p License# S ( � i g 7 Sticker# ❑Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# - ❑Temporary Food Facility—Dates ofoperation from to El lee Plant ❑ Special Event -Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑Grade A Dairy ❑ Grade B Dairy ❑Miik 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(221 s) ❑ 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 USTA and B forms HOUSING PROGRAM(2400) ❑HoteUMotd—Number of Units -❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use F.mplopee IfousinzlLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) _ ❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned 11W Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site ' RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility- ❑P9ol ❑ Spa ❑Out of Service Pool/Spa ❑Nataml 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 OChemical 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/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care 1 ❑Acute Care ❑ SkilledNursing ❑Large Generator 17 Small Generator ❑Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10—1:111-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PN'SE/fD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON pDay Ph - 7 " �� Night Ph PROGRAMELEMEN-r FEE '� O Surcharge FEE ❑ Other FEE INSPECTOR2PERMIT VALID I ( to i U31 / ❑Food Handler p ❑Check R AMOUNT PAID O {- 0 Date g INVOICE# CP-10 7 Cash REVIEWEDBY AccourmxGOmcE Date Macule Record Pink