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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM PAYMENT <br /> ❑New EH Program at Existing Facility []New Eli Progrun and New Facility RECEIVED <br /> Facilit W D al(,3,;;L- `° Pra ramRecordlD JAN 12 2012 <br /> x Facility Address 343 i✓- /"/b/si 1-1� SAN JOAQUN COUNTY <br /> EWROMMENTAL <br /> (Please Check the appropriate description and specify Eim,number of units and pertineut information) HEALTH DEPARTMENT <br /> FOOD PROGRAM(1600) <br /> []Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yrs❑ No❑ <br /> ❑ Commissary ❑ Drystorage 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 0 Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from - to ❑ lee Plant . <br /> ❑ Special Event —Dates of operation from - to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Numbs of Containers in Multi-Head Unit <br /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator--Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) _ ❑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/Mold Number of Units 0 Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F nployee 1Iausine/La6or Camp Anpfimliou Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned MY Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service PoolfSpa ❑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(4 120) ❑Permaamt Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200 gg�,,w�v--dd�� _ <br /> V R Pumper Vehicle—Registration# -2�47�G.�b�nl ZYcea # '�'KIoIQJi✓i Capacity � �7`C'G Vehicle-# N�ik <br /> Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag l Cannery Waste Site ❑ Sludge/Ask 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 /> ❑ Primary Care ❑Acute Care ❑ SkilledNursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10—❑ H-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PII'SEWD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> l CONTACT PERSON 6-11" c42 _ Day Ph jA<Ie� Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcha e F E ❑ Other FEE <br /> INSPECTOR# P RMrr VALID 1 ni 'L to I?i h'l 1 ❑ Food Handler <br /> Check Y (O,�7i� TPAID to <br /> t 1 INVOICE# <br /> ❑ cash REVIEWED ACCOUNTING OFFICEZL---Date 3 Z' <br /> ,� �„ Macule Rccord Pink <br />