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0 PAY T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � D MASTERFILE RECORl7 INFORMA.TI N FORIA APR 2 2 2013 17 New EH Program at Existing Facility New EH Pro • and New Facility QUIN COUNTY Facility ID Pra ram Record ID (�J� SA Ej V pOMENTAL HEALTH DEPARTMENT Facility Address Slt N,Uni (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM 0600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ MuItiple Departments ❑ Prepackaged Goods Only ElMobile Food Vchicle--Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# 11'Temporary Food Facility----Dates of operation from to 11 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-Bead Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) f` ❑Hazardous'Waste Generator..- Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(221 7) 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) ❑ HoteUMotel Number of Units .❑Jail or Exempt Institution Number of Units Employee housing(2700)Use Employee IfousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑Environmental Assessment ❑UST-CAP Site 11 Local II�V Cleanup Site. L1NPLISEP Cleanup Site ®UIC Site ❑Abandoned MY Site ❑non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑'Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PoolstSpas at Facility. ❑P®ol ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathiag Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel Y TTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) Tattooing(4121) `Qc��,}�n art—w'>> ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration,# License# Capacity Vehicle# 11 Pumper Yard ❑Package Treatment Plant- ❑Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) C❑ Landfill ❑ Transfer Station ❑Ag I Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsfers>20 cu yd—Number of Units ❑FaraVRauch Cleanup Site MEDICAL WASTE PROGRAM(4500) [3 Primary Care ❑Acute Care ❑ Skilled'Nurs'mg ❑Large Generator Cl Small Generator ❑ Limited liauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'S Elm 46-02-003 Blue Application Fonn �^ EMERc NCY NOTIFICATION FORTI{iS FAC LITY ANDIOR PROGRAM CONTACT PERSON ' l l h 5 Day Ph 511) 7ii. Night Ph — — i PROGR_hmELEMENT FEEj ❑Surchar eFEE '- ❑ Other FEE — INSPECTOR# 'bG 6t,04t)PERMITVALID pCVC to +-25 El Food Handler_ ❑ Checkf AIStjC�>(TT�rNTP ID _�-✓ -- — Date J INVOICE --- _ash REVIEWFD BY '�+" u 27i l 1 ACCOtTI�TITaG JFFICI Dale 2 _�= i ---