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'R A <br /> SAN JOAQUIN COUNTY ENVIRONM...CNTAL HEALTI-I I) M <br /> PAIkTrNT PAYMENT <br /> RECEIVED <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑Now EH Program and New Facility FEB 2 2 2008 <br /> Facility ID l 2 Pra rani Record ID SAN JOAQUIN COUNTY <br /> VNViRONMENTAL <br /> Facility Address}_�Zj _ f���[ ��. t # T HEALTH DEPARTMENT <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No❑ <br /> D Commissary ❑ Dry storage only ❑with Food Preparation [ trending Machines Number of Units <br /> ❑ Retail Market Square footage ❑with Meat Market only ❑MuItiple 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 /> [3 Temporary Food Facility-----Dates of operation from to ❑ Ice Plaut <br /> 13 Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> h <br /> 0 Grade A]Dairy 0 Grade B Dairy 11 Milk Dispeaser Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) f <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f 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 /> ❑Pclmit-By Rule Faced 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 /> ❑Rotel/Motel Number of Units Jail or Exempt Institution Numbcr of Units <br /> Employte Housing(2700)Use Employee Wo asinzlLabor Camp Applica(ion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned MY Site ❑ noa-NPLISEP Cleanup Site ❑R\VQCB 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) <br /> ❑Pumper Vehicle—Registration# License# capacity Vehicle# <br /> ❑Pumper Yard ❑ Package Treatment Plant Chemical Toilets Number of Units r f <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag f CanneryWaste Site. ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled'Nursiag ❑Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility----D 2- 10—El 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UseYif'SCIfD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION ron Trims FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON G CI Z- Day Ph Night Ph �00 `130 <br /> rRoGRAM ELEMENT FEE Surcharge FEE '. ❑ Other FEE <br /> I�N(SSPECTOP# PERMITVALID fl { iS _ to p ❑Food 1landler <br /> �9check AhIOUNT PAID c-�V0�DD Date INVOICE# 173 6-7 <br /> D Cash REViSWEb i3Y ACCOUNTING OFFICE Date d <br /> ?kbb,#3 G Sb neo Xe <br />