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SAM JOAQUIN COUNTY-tNVIRONMENTAi, HEALTH DIVMON MASTERFILE RECORD LYFORiyL4TI0N FORM(EH 00 69) PAY MENT ❑New EH Program at Existing Facility ❑New EH Program and New Fiicillty RECEIVED Facility ID Program Record ID p Facility Address MAY 7 2004 (Please Check the appropriate description and specify side number of units and pertinent information.) SAN JOAQUIN COUNTY ENVIRONMENTAL FOOD PROGRAM(1600) c HEALTH DEPARTMENT ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ ❑ Commissary ❑ Drystorage 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 X License m Sticker X ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant Cl Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy n A ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA 11n State Facility Surcharge(2399) //t/ D 3 9 IL&ZARDOUS WASTE PROGRat ❑ Hazardous Waste Generator--------------Tons Generated Per Year 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) ❑ Hatel/Motel-------Number of Units ❑Jail or Exempt Institution—Number of Units Employee Housing(2700) Use E oloyte Hcusine/Lahor Cama Appiica(toa Farm SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site ❑ abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Naruml Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration 9 License# Capacity Vehicle N ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets=Number of Units SOLID WASTE PROGRAM(4400) k - - ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number 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 EHOO69 B/ue Application Form �/ EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM /,fAyQ37 CONTACT PERSON Day Ph Night Ph �4 PROGRAM ELEMENT 2ZZo FEE r� �� ❑Surcharg4FEE 110ther FEE L4�_'� y _ INSPECroR1l PERMIT VALIDTj� to ,.. ❑Food Handler — b Check# �� E "'> AMOUNT PAID Date - � i i C`> i''.Y INVOICE# i ( 7�i✓_? ❑ Cash REWEwFD BY ACCOUNMr,OFFICE - ` ' Date h_ / r EH 0069 PINK FORMAnc -- - - Rev.07NL99