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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAYMEMr MASTERFILE RECORD INFORMATION FORM RECE VE6 New EH Program at Existin Facility []New EH Program and New Facility DEC _ 7 2010 Facilif H) 0 (7��3` Pro ram Record ID a-c;, 5-?S—Aca3 �yIAQQUIN ppUNn N�-7H DEPAR�a" Facility Address 7 ��• lva l I C�,� rte FS TMENT (Please Check the appropriate description and specify E!T_�,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Sealing Capacity Square Footage Food Handlers Course required:- Yes�( No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackpged Goods Only V Mobile Food Vehicle—Make Vehicle Type r iColor cker# !Q.'im' Q Vi -P2Uw� I T]I Itin 9 censeRegistration# �_— ❑ Mobile Food 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 11 Produce Stand DAIRY PROGRAM(2000) - ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit CU PA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) r ❑Hazardous Waste Generator--Toru Generated Per Year ❑Recycle!Exempt System(2299) ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(221 7) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotet/Motel Number of Units 1]Jail or Exempt Institution Number of Units Pmployee Rousing(2700)Use Fmpfovee HousinKabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local 11W Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC site ❑ Abandoned IIW Site 13non-NPIJSEP Cleanup Site 11RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) - ❑Poultry Farm—Maximum number of birds Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4 120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) 13 Pumper Vehicle—Registration# License# Capacity Vehicle ❑ Pumper Yard —ff Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑SludgelAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/6auch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-11 2-10—❑ 11-60--❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'S F,IID 46-02-003 Bfue Application Fonn EMERGENCY NOTIFICATION FOR TH15 FA ILITY AND/OR PROGRAM CONTACT PERSON ��JF mNb 0 lz z9 ,,/lQF Z Day PI 2 5- ..g>5 5�ight Ph PROGRAM ELEMENT FEE */�/"S��` ❑ Surcharge FEE . ❑ Other FEE INSPECTOR# PERMIT VALID X A I l I_ V) to \2— �I� (-� 11Food Handlerp �" ❑ Check# AMOUNT PAID HS Date \21110 IYZ•r INVOICE#II A071, Lt) Cash REVIEWED BY Grp 0 3 ACCOUNTING OFFICE Date 4