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w •t PAYMENT <br /> RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEiv 1 <br /> MASTERFILE RECORD INFORMATION FORM I JAN 12 2006 <br /> ❑New EH Proam at Existing Facility ❑New EH Pro am and New Facility SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> FacilityID A./ Pro ramRecordID r"S'�� <br /> HEALTH DEPARTMENT <br /> Facility Address Ilttt lAtI//O-77 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) 7 <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ,Mobile Food Vehicle---Make Vehicle Type `yX Color <br /> Registration# / S License# ?///DZZ3 Sticker# 1-2-51 <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator-----Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel--Number of Units ❑Jail or Exempt institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor-Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑Abandoned RW Site ❑non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant. ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator 13,Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2-10---❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS ERD 46-02-003 Blue Application Form <br /> EMERCYN FICATION R THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 11 ',/ Day Ph 4o`I-d'2�- gQI/ Night Ph Q-�7F-'S�._Zl <br /> PROGRAM ELEMENT t L2 SW FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR#yCiSp��Z^^"`^^^---"`---ttt--P--E—RM—MIITVALID IZDb to (�j I l041 13 Food HandierrL <br /> Check# p 11�3� T AMOUNTPAID 7Y-- Date t�l�OL y� INVOICE# IT3'1 OS <br /> ❑ Cash REVIEWEDBY ACCOUNTING OFFICE - Date ( 13 cu <br /> 48-02-034 Masterfile Record Pink <br />