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i PAYMENT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION RECEIVED MASTERFILE RECORD L tFORiV1ATION FORitiI(EH 00 69) ❑New EH Program and New Facility AUG 17 2000 13 New EHPro am at ExistingFacility / hoz�9 Program Record ED } SAN JOAQUIN COUNTY Facili ID PUBLIC HEALTH SERVICES FacilityAddress C ENVIRONMENTAL HEALTH DIVISION (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) [I Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes C1 No ❑ ❑ Commissary ❑ Dry storage only . ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage Elwith Meat Market only C1 Multiple Departments C3 Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# C1Temporary Food Facility----Dates of operation from to C3 Ice Plant C3 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 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) C1 Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution dumber of Units Employee Housing(2700) Use Employee Housing/Labor 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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility Cl Pool 1:1 Spa ❑ Out of Service Pool/Spa C3 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) C1 Poultry Farm Maximum number of birds C1 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) C3 Tattooing(412 1) ❑ Body Piercing(4120) C3 Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) C3 Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) 11 Landfill C1 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 ❑ Acute Care ❑ Skilled Nursing ,'Large Generator ❑ Small Generator ❑ Limited Hauler C1Transfer Station C1Veterinary Clinic ElCommon Storage Facility —❑ '_- 10--❑ 11 -60—11>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form EMERGEN Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 0, Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE LNSPECTOR# {' ? D ❑ Food Handler PERbtIT VALID �! -�{� to J 3 L"J Check# gP 70 /r 3� AMOU`1T PAID �/S� Date i �� C INVOICE# ❑ Cash REVIEWED BY j f . ACcOUVrIN2 QFFICE Date EH 0069 PINK FORM.doc Rev.07/07/99