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SAN JOAQUIN COUNTY L . . r/ IRONMENTAL HEALTH DEPAR evIENT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVED ❑ New EH Program at Existing Facility 2 new EH Program and New Facility Facility ID d� g7 Program Record ID ` %DEW e 20 7 Facility Address � v � 1- 0 �yL Uc }`I q � ay D SAN JOAQUIN COUNTY I ENVIRONMENTAL (Please check the appropriate description and specify size , number of units and pertinent information . ) HEALTH DEPARTMENT FOOD PROGRAM ( 1600 ) ❑ 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 ❑ w/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 ❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser - Number of Containers in Multi - Head Unit CUPA ❑ Hazardous Materials Business Plan ( 1900) Number of chemicals : ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- > Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233 , 2234 , 2235 , 2237) ❑ PBR (2231 ) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program ( UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution - --- Number 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 ❑ 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) ;2 Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121 ) ❑ Body Art Temp Event Co -ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131 ) 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 (# or 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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ` , EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1 � o 04 ; e L v l Day Ph uq 1 Night Ph PROGRAM ELEMENT . 41 r> FEE f I QZ ❑ Surcharge FEE ❑ Other FEE INSPECTOR # 7,JQVZi PERMIT VALID o2 to 4'13 / ) 7 ❑ Food Handler. Check # ( � `f AMOUNT PAID 3 � ` Date •a \ INVOICE # C*1 �� ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date �� 48-02-034 MASTERFILE RECORD INFORMATION PINK 1 /23/13