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PAYMENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> MASTERFILE RECORD INFORMATION FORM I JUL 05 2023 <br /> ❑New EH Program at Existing Facility ew EH Pr ram and New Facility <br /> Facill ID TAOD�LW65 Program Record ID 0 S 2 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Facility Address S(-sl I°Y6, Igo° k 946 V-A,*A C 2- HEALTH DEPARTMENT <br /> (Please check the appropriate description and specify llzg number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation [Wending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA O State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and 8 forms <br /> OUSING PROGRAM(2400) <br /> HoteVMotel—Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700)Use Employee Housina/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 2- pfPool Spa El Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm---Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(r of Units) ❑ Dumpsters>20 cu yd I#of units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR R RAM <br /> CONTACT PERSON I Day Ph S 6 2-fP 4 (o-43-`bNight Ph <br /> PROGRAM ELEMENT 361 1 FEE 141.5 ❑ Surcharg F ❑ Other FEE <br /> INSPECTOR# 9828 PERMIT VALID S to �� 31 .L— ❑ Food Handier <br /> ❑ Check* AMOUNT PAI I'fI Date INVOICE 38 3� <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 17 '> <br /> 48 1 Z- MASTERFILE RECORD INFORMATION PINK <br /> 11/15to7/15/07 <br />