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SAN SJ)AQUIN COUNTY E1\ . �RONMENTAL HEALTH DEPART.__ NT PAyyiENT <br /> MASTERFILE RECORD`INFORMATION FORM RECEIVED <br /> "Jew EH Program at Existing Facility ❑New EH Program and New FacilityI FEB 2 8 2012 <br /> Facility H) t-1rU17 1 L Pro ramRc ordID ILC I � e"JOAQUINcOuNTY <br /> EWRONMEXrAL <br /> Facility Address. T /V �Ut L/ �L4:11 HEALTH n�ARnElrt <br /> (Please Check the appropriate description and specify see number of units and pertina t information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ Nola <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 –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 WASTE PROGRAM(2200) t <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 /> ❑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 11 Jail or Exempt Institution Number of Units <br /> Employs Housing(2700)Use Employee ILousinglLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) . <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local Inv Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPL/SEP Cieanup Site ❑RWQCB Cleanup Site '❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ 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) ❑Permane¢tCosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑pumper Ythicle–Registration# License Capacity Vehicle# <br /> Cl Pumper Yard - - ❑Package Treatment Plant ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> -❑Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator D Small Generator ❑Limited Mauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--❑ 2-10—1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePWSEAD 46-02-003 Blue Applieadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PR GRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT W FEE ❑ Surcharge FEE . ❑ Other FEE <br /> INSPECTOR# r� PERMIT VALID Z to___. . - _ ❑ Food Handler <br /> ❑ Check# AMC PAID I ' �� Date \Z INVOICE# -7 <br /> 'EYCash REVIEWED'BY (/J ACCOUNTING OFFICEi Date <br /> , -1, Maa,,file Record Pink <br />