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PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED MASTERFILE RECORD INFORMATION FORM APR 16 2010 ❑New EH Program at Existing Facility 06ew EH Program and New Facility SAN JOAQUIN COUNTY �A- ENVIRONMENTAL Facilit •ID t O �a Program Record ID D3 HEALTH DEPARTMENT Facility Address (Please Check the appropriate description and specify size•number of units and pertinent information) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ No ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Pending Machines-Number of Units ❑ etail Market—Square footage ❑with Meat Market only ❑Multiple Departments Prepackaged Goods Only ) Mobile Food Vehicle--Make Vehicle Type �- Color WRIl'E- Registration# License# Gn%& Sticker# S ❑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(2219) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Pcrrnit-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) ❑ HotcVMotcl—Number of Units .❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Employee Housine/f abor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IfW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. []Pool ❑ Spa ❑Out of Service PooUSpa ❑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) ❑ Landfall ❑ Transfer Station ❑Ag f 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 . ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limiied Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—.0 2-10—1111-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PHSEHD46-01-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON St--401j R-F—g eS Day Ph Si— fight Ph PROGRAIIIELEMEINT ( (036 FEE 93-J\7 ❑ SurchargeFEE ❑ Other FEE INSPECTOR# (r{"LD PERMIT VALID . 4k4j 6 j j D to II,41. 3"I 10 ❑ Food Handler ElCheck# AMOUNT PAID 1B 91, "ISD Date 1 6110 6116- INVOICE# -Z02-35S S Cash REV7EWEDBY 60D3Z' ACCOUNTING OFFICE 7.-�—Datc 7 ly p