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SAN JOAQUIN COUNTY EN _IONMENTAL HEALTH DEPARTI 1T PAYMENT REQ_. ED MASTERFILE RECORD INFORMATION FORM New EH Program at Existin Facility - L�New EH Program and New Facility FEB 0 7 2012 Program Record ID �LOS� 7 w+.loAnu► NTAL " Facilit ID 00 (o2°— HEALTH DM%RTME �i Zy IEALt11 DQ'AR7Y9Ir Facility Address �iS to '� 2 k12Y OW• ' S' 0 C K I n C q . 20 (Please beck the appropriate description and specify 1ILS number of units and pertinent information) FOOD PROGRAM(1600) ( Restaurant: Seating Capacity uare Footage Food Handlers Course required: Yt� 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 i ❑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 Dispeaser—Number of Containers in Multi-Head Unit v cUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) . f ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Ezem ystem(2299) ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyc s(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionallyy xempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit- y"kule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST - UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use=erpt HOUSING PROGRAM(2400) ❑ Hotel/Motel Number of Units .❑Jution Number of Units Employee lfousing(2700)Use Emploree)lousinclLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND 1 JECTION CONTROL(3000) -❑ Environmental Assessment ❑USP-CAP Site ❑Local H\ eaaup Site. ❑NPIJSEP Cleanup Site ❑UTC Site ❑Abandoned HAY Site ❑non-NPL/SEP Cleanup Site RR'QCB Cleanup Site '0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P901 Spa ❑Out of Service Pooppa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) - ❑Poultry Farm—Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT OSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration License Capacity Vehicle# ❑Pumper Yard ❑PackageTreatmentPlant ❑ Chemical Toilets—Number of Units SOLID WASTE PROG (4400) ❑Landfill ❑Transfer Station ❑Ag I Cannery Waste Site ❑ SludgdAsh Site ❑Waste Tire Faci' y ❑ Compost Facility ❑ Proms/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehi s—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmtRanch Cleanup Site MEDICAL STE PROGRAM(4$00) -ZP Care ❑Acute Care ❑Stilled Nursing ❑Large Generator ❑ Small Generator ❑LimitedHauler Station ❑VeterinaryClinic ❑ Common Storage Facility--❑ 2-10—❑ 11-60--❑>60 generators ATER SYSTEM PROGRAM(4600)Use PWS ERD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR Tins FACILITY ANDtOR PROGRAM CONTACT PERSON /O/(`7iSn .o Day Ph / 6,0z/ /0&1 Ph G16- �`/� / L PROGRAM ELEMENT /(od O FEE ❑ Surcha eFEE ❑ Other FEE INSPECTOR# 3,3 PERMIT VALID . A'�. �Zl to A A ❑ Food Handler l ❑ CheckR AMOUNT PAID Date INVOICE# Z h REv1EwEli'BY 3 l 2-t( ACCOUNTING OFFICE Date -. , Ma<teTle Record Pink