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SAN JOAQUIN COUNTY ENVIRONM.ENTAL HEALTH DEPARTMENT PAYMENT MASTEUME RECORD INFORMATION FORM RECEIVED F ❑New Ell Pro at Existia Facility ew EH Progmm and New Faclli JUL 9 2011 Facility I 9 7 Program Record ID .'PR ?05 �� SAN JOAQUIN COUNTY .- �TI-iPARTMENT 1� N � �1 Facility Address �-, H (Please Check the appropriate description and specify Lktl number of units and Rertlneu information-) t FOOD PROGRAM(1600) f ❑Restauraat: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ Na ❑ ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Fending Machines Number of Units ❑Retail Market----Square footage ❑with Meat Market only ❑Multiple Depart newts ❑Prepackaged Goods Only ❑ Mobile Food Vehicle----Make Vehicle Type Color Registration# License# Sticker# I-]MobileFood 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 Dalry ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) HAZARDOUS NVASTE PROGRAM(2200)' 9 ❑Hazardous Waste Generator—Tons Generated Per Year _ '❑Recycle[Exempt System(2299) ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Excmpt(CE) ❑Permitt By Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACELITY(AST)(2390) Number of AST .UNDERGROUND STORAGE.TANK(UST)PROGRAM(2300)Use UST.t and B forms HOUSING PROGRAM(2400) ❑HotdWotd Number of Units .❑Jail or Exempt Institution Number of Units Employsc Housing(2700)Use Baatoyei gousLn&Exbor Como Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 13 Environmental Assessment E3UST-CAP Site E3Local HW Cleanup Site• L]NPLISEP Cleanup Site 13 UIC site E3 Abandoned HW Site ❑non NPLlSEP Cleanup Site ❑RWQC8 Cleanup Site 1❑Water Quality Remediation Site ' ECREATION AL HEALTH PROGRAM(3600) Number of PooWSpas at Facility. ❑P99l ❑ Spa ❑Out of Service PoollSpa ❑Natural Bathing'Area VI=CTOR CONTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TATTOO,BODY PIERCING,PIERMANENT COSMETIC PROGRAM(4100) ❑Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4201))_ -Pumper Vehicle-Rogistratioa#�f D�'� b t�3 6 E License# xl yD0 3� c7 —Yzwcic_# a 0-pumper Yard ❑ Package Treatment Plaut- emical Toilets umber of Units 6R- SOLID WASTE PROGRAM(4400) ❑Landfill ❑Transfer Station ❑Ag/CanneryWaste Site ❑SludgelAsh Site ❑Waste Tire Facility ❑Compost Facility ❑ProcesslRerycle Facility ❑ CIA-Landfill Site ❑Refuse Vehicles Number of Units ❑Dumpders>20 cu yd---Number of Units ❑FarmlRauch Cleanup Site MEDICAL WASTE:PROGRAM(4500) ❑ Primary Care . ❑Acute Care ❑ Skilled'Nursiag ❑Large Generator l7 Small Generator ❑Limited Hauler ❑ Transfer Station '❑Veterinary Clinic . ❑ Common Storage Facility-----❑ 2-10 ❑ 11-60----❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 4642-003 BlueApjzlicadern Form EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM CONTACT PERSe ar Day P O CC PROGRAM EI.EM _ �_�?�rzFE & I- � �� Surcharge FEE © Other FEE INSPscrOR# o y S ERVALID . '7 I 1 to MIT t –131 ❑Food Ifandlero Check p 431- :�_ A1vI U T PAID ig P'-D 7C:) Date ! f It w010E# ;7-4 O a Cash l2EviEWEU'SY !p—ACCOVNTINGOFFICE Date � [�.