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PAYMEN i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION AECEIVEO • MASTERFILE RECORD INFORMATION FORM EH 00 69 ❑ New EH Program at Existing Facility ew Eli Pro gram and New Facilit LIAR .11 5 2002 Facility ID �Io Program Record ID h� ✓''''1 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES Facility Address yY:�z a Ey FK1-- 'NVIRONMFNTAI HFAIIHDIVISI!,., (Please Check the appropriate description and specify side,number of units and pertinent information.) FO ,D PROGRAM(1600) Restaurant: Seating Capacity�- Square Footage Food Handlers Course required: YES�Y0 E]r_1Commissary ElDry storage only Elwith Food Preparation []Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with Mcat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile hood Vehicle-----Make Vehicle Type Color Registration# License It Sticker It ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration It License It 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 Dispcuscr---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) ❑ 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 TANI{(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 Enrnloyee flo«sing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local I-iW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW 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 It 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--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 IIauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----El 2- 10-------❑ 1 1 -60------❑ >60 generators PUBLIC WATER SYSTEM PR (4600) Wye PWS EH0069 Blue Application Foran E Y^ OTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON� Day Ph - Night Ph ,// 5 PROGRAM ELEMENT z FEE D ❑ Surchar c FEE 13 Other FEE INSPECTOR# PERMIT VALID 3��5�o L to z31 3 4 03 ❑ Food Handler ® Check# + L AMO NT PAI 2.2 C) Date .-/15�pt- INVOICE It t{ 71 Cash REVIEWED BY ACCOUNTING OFFICE Date 3/15/0