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4 SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR PT PAYMENT MASTERFILE RECORD INFORMATION FORM RECEIVE p ❑ New EH Program at Existing Facility ❑New EH Program and New Facility JUN 13 2014 FacilityID D0"6q Program Record ID c3 SAN EN�V"1iRQOUtNCOUNTy Facility Address 136 5 cS�cr�r�e✓lfa ,S� �� ,rte ' "DEPARTMENT (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating 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 ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color ,,��// Registration# License# . Sticker# y' LMMobile Food Prep Unit--Make Vefii`cle Type 1(- Color (ti CCCCCC Registration# 11-rU e,5 Z53 V- License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy/ ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233,2234, 2235,2237) ❑ PBR (2231) ❑ PER HHW(2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3500) 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (#of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form _ EMERGENCY NOTIFICATION FOR T..s FAC TYAND/OR PROGRA CONTACT PERS L ! C� Da /p Night Ph 5Ut2c� 0 PROGRAM ELEMENT Ib y/ FEE 'r-0 3 ❑ Surcharge FEE El Other FEE INSPECTOR# lM1i �PERMIT VALID ./ ,3 t0 1 'I ❑ Food Handler ❑ Check# AMOUNT PAID a2(.(,).bd Date p INVOICE# /Cash REVIEWED BY ACCOUNTING OFFICE / f Date 49'02-034 ., MASTERFILE RECOFID INFOR ATION PINK 1/23/13