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"SAN TOAQUIN COUNTY ENVIRONMENIrAL HEALTH DEPARTMENT PAYMENT <br /> MASTERFILE RECORD INFORMATION FORM RECEIVED <br /> ❑New EH Program at Existing Facility PNew EH Program and New Facility MAR - 8 2012 <br /> Facility ID u Pro ram Record ID l)--0 53 /15�) s,"JOAQUIN coUWrf <br /> Gt <br /> HEALTH DEPARTMENT <br /> Facility Address f . � !, '��Vh, 71��/ DNNENTAL <br /> (Plcasc Check the appropriate description and specify Ejz number of snits and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple 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 /> ❑Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dated 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 WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑Appliance Reeyclers(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 /> ❑ Botd Wotel Number of Units 0 Jail or Exempt Institution—Number of Units <br /> Employ"Housing(2700)Use Employee frousin&EAbor Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Eavironmeatal Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑non-NPL/SEP 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) - [1 Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> PumperVehicle—Registration# 4EjDUA-66 P,,c->✓ License# �/�7�/�/ Capacity Vehicle# '4114 <br /> Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle 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 /> 13Primary Care . ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited ITauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10—❑ 11-60•--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIPS EIID 46-02-003 Blue AppficadaA Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON /-F'U.111�-f!�[71 /�El�/Il Day Ph QJ�'Z—�(�' Night Ph I�'6/-L3 <br /> P120GRAM ELEMCEghTL,L ! Z Ll I FEE Se •1) ❑ Surcharge FEE ❑ Other FEE <br /> I�-N�(SPECTOR# .J `-Il PERMITVALID c1 I2— to �p�1 ) ❑ Food Handler <br /> y(r.Chcck ff �.s.�� AMOUNT PAID $ 15-r• 0-0 Date O Z INVOICE# 1Z--1 w <br /> �❑ Cath REVIEWED BY AccouimNG OFFICE Date <br /> Macule Record Pink <br />