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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT F� MASTERFILE RECORD INFORMATION FORM RECEIVED New EH Program at Existing Facility ❑New EH Program and New Facility JUN 16 2010 Facility ID D 0 d b O Pro ram Record ID S3 L SAN JOAQUIN COUNTY �. Z_Ot7 ✓ C–O.OI � �2r{Q HEALi}{DEPARIMML FacilityAddress (vC� t '4NT (Please Check the appropriate description and specify LjK�,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Stating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vendiug Machines-Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only i AMobileFood Vehicle-Make Vehicle Type 0:421 Color SrwE2 Registration# License# Sticker# _ — ❑Mobile Food Prep Unit-Make Vehicle Type — Color— Registration olorRegistration# 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) 4 ❑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 forms HOUSING PROGRAM(2400) ❑HotellMotel—Number of Units .❑Jail or Exempt Institution—Number of Units Employee Housing(2700)Use Fmploree 7fousine/La6or Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned HW Site ❑non-NPIAEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility. ❑P901 ❑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(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 ❑ Process/Recycle Facility ❑ CIALaudfill 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--13 2-10—❑ 11-60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PNS EMD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 36q-7a45 Night Ph PROGRAht ELEEMEN"T ((0313 — FEE 13e-OO ❑ Surcharge FEE ❑ Other FEE INSPECTOR# (p Zf3 PERMIT VALIDto ❑ Food Ilandlerr ❑ Check# AMOUNT PAID 0 C7Tj Date t-1 INVOICE# X4-1 ash REVIEwEDBY &D 1932-/ ACCOUNTING OFFICE Date __ "_ . nM�n•rGl.R,,A Pink