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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTI RENT PAYMENT <br /> MASTERFILE RE <br /> CORD`INFORMATION FORM RECEIVED <br /> ❑New EH Program at Existing Facility New EH Program and New Facility MAY - 4 2012 <br /> Facility ID Program Record ID a-C 53_7C 5 SAN JOAQUINECOUNTY <br /> Facility Address X73 W HEALTH DEFARTNrMENT <br /> (Please Check the appropriate description and specify siz number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course ret aired:. Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage— El with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> 11Mobile 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 ❑ State Facility Surcharge(2399) <br /> HAZARDOUS NVASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator- Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(z222) c ❑ 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 B forms _ <br /> HOUSING PROGRAM(2400) - - <br /> ❑Hotel/Motel Number of Units I]Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housine/La6or Camp Anplieatiou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑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) �J <br /> umper Vehicle_Registration# q License#-7 2 Capacity �7 e�C Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant Chemical Toilets—Number <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site - <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch 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--El 2-10—❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PfVS ELM 46-02-003 Elite Application Forst <br /> .EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON_'V-1C tom- 4M- 6L4, ate <br /> r - ()Night Ph <br /> PROGRAMELENIEATL gI241�-' FEE Surcharge FEE ❑ Other FEE <br /> INSPECTOR# E4 r� tj7r PERMIT VALID . to I 2— ❑Food Handler <br /> 1 (Chcck# `1-Ia3 AMOUNTPAID '� �/2-- INVOICE# ✓q`� 2 <br /> ❑ Cash REVIEWEDBY GiO Z ACCOUNTING OFFICE Date <br /> • tTl`.SLJ ( <br />