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SA11 N JOAQUI111 N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMENr MASTERFILE RECORD INFORMATION FORM NECEtVED ❑ New EH Program at Existing acility 77jNew EH Program and New Facility. - ;� 1 2017 Facility ID '400;2i3 ' 7 Program Record ID— f/ SAN JOA QUIN D (P- (� l,C� � �/� � ! / Sd ENVIRONMENTAL TY Facility Address1 HEALTH DEPARTMENT ( Please check the appropriate description and specify size , number of units and pertinent information . ) FOOD PROGRAM (1600) El 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 ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit Make _ Vehicle Type Color Registration # 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) ❑ 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) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700 ) Use Emplovee 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 ❑ Pool ❑ 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 ❑ CIA Landfill Site ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm /Ranch 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 112 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46- 02- 003 Blue Application Form EMERGENCY NOTIFI ATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON k Day Ph Night Ph I PROGRAM ELEMENT ?. I I2� FEE (Sa� ElSurcharge FEE ElOther FEE INSPECTOR # p '22 PERMIT VALID ( a0 �O 3v ❑ Food Handler �,� heck # AMOUNT PAID [9 d70 Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11 /15/07