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SAN JOAQUIN COUNTY ENVIRONM.El NTAL HEALTH DEPARTMENT PAYMENT <br /> MASTRMFlY.E RECORD-7NFORMATION DORM RECEIVED <br /> D New EH Program at Existing Facility Eli-Program and Nei),Facility AUG 1 7 2012 <br /> v oAN JOAQUIN COUNTY <br /> ro <br /> Facili )U P / am ke/cardlD Y i` ' J /�j ENVIRONMENTAL <br /> Facility Address / `t/ �`Ul� W � �� ��( 7 `' ATN DEPARTMENT <br /> (PleCheck the appropriate ri scription and specify lKt numbe <br /> ase r of units grid pertinent tuiormation.) <br /> FOOD PROGRAM(1600) <br /> D Restaurant: Stating Capacity Square Footage Food Handlers Course re aired•- Yi s❑ No D <br /> ❑Commissary D Dry storage only D with Food Preparation DNtending Machines Number of Units <br /> Retail Market---Square footage D with Meat Market only D Multiple Departments ❑Prepackaged Goods Only <br /> ❑Mobile Food Vthiele---=Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> D Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# Lige# Sticker# <br /> D Temporary Food Facility----Dates of operation fmiri to - D Ice Plant <br /> p Special Event Dates of operation from to DProduce Stand <br /> DAiR1f PROGRAM(2000) <br /> D Grade A Dairy E3 Grade B Dairy D Milt..Dispenser Number of Containers.in Multi-Read Unit <br /> 4-L CUPA CI State Facility Surcharge(2399) <br /> IiAZARDOUS WASTE PROGRAM(2200)` f <br /> D Ilaza+rdous Waste Genera for. Tans Generated Per Year D Recycle t Exempt System(2299) <br /> D CRT Offsite Handlers(2218) D Silver Only(2222) " O Appliance Recyclers(2iw) <br /> Tiered Fermitting Facility D Conditionally Authorized(CA) D Conditionally Exempt(CE) - <br /> D Permit ByRule Fixed Unit D Permit By Rule household Hazardous Waste <br /> D ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numb r of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> D Aotelmotel----dumber of Units 13.Tail or Exempt Institution Number of Units <br /> Erttpioree 13oasiag(2700)Use ►r oyee Housinr<ILabor Camp Applieatroa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> I3 Enviraamental Assessment D UST-CAY Site -L7 Local HW Cleanup Site. ❑NPLISEP Cleanup Site ©UIC Site <br /> D Ahandoned HW Site D non NPUSEP Cleanup Site d RNVQCB Cleanup Site -Cl tiVater Quality Remediation Sita <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Poowspas at Facility_ D r9ol D Spa D Out of Service PoolPSpa D Nat"Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> D Poultry Farm Maximumnumber of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PICOGRAM(4100) <br /> 53 Tattooing(4121) D Body Piercing(4120) [3 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM.(4200) <br /> [3-ramRognstration# Liceiueil Capacity, Vehicle# <br /> D Pumper Yard Q Package Treatment Plant. D clieuaical Toilets Narnber of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill Q Transfer Station I3 Ag I Cannery lVaste Site D SludgdAsh Site <br /> D Waste Tire Facility D Compost Facility D ProcesslRecyde Facility C3 CIALxndfill Site <br /> D Refuse Vehicles Number of Units ❑Durr>psters>20 cayd-Number of Units • Q Farmtltaach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> D Primary Care ' ❑Acute Care D Skilled Nursing 13 Large Generator 17 SmaU Generator D Limited Hauler <br /> D Transfer Station D Veterinary Clinic D Common Storage Facility O 2-10 D 11-60---D>60 gerremtors <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPSEAD 4602-003 BCueAppliartiorc Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR P t?GRAM <br /> CONTACT PERSON /'n, �!� Day Ph Night Ph <br /> PROGRAM ELEMENT <1110FEE D Surcharge FE [I Other FSE <br /> irtsescrt►R# I'lC O <br /> cM PERMiI VALID . to L7 Food handler <br /> D Check# AMOUNT PAID Date INVOICE# <br /> Cash Rnvrsvri:n-BX AcCDU nNG OFFIM Date j 2 <br /> Macterrilc Record Pink <br />