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SAN JOAQUIN COUNTY EN r RONMXNTAL HEALTH DMSI - , b1ASTERI+`ILE RECORD INFORMATION FORM FSH 00 69 El Ncw EH Program at Existing Facil ❑blew EH Program and New F*cillty [ F'acill ID _ - Pi ro-g arh, c6rd TD Facility Address 37 west Sonora Street (Please Check the appropriate description and specify jim number of unks and Rertiwnt inform7ition.) Feor PIa0r�ItAAl1(1600) ❑Restsuraat: Seating Capacity _ Square f=ootage Food Handlers Course rN11ired: Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food preparation ❑Vending Machines—Number of Units Q Retail Market----Square footage ❑ with Meat Market only 0 Multiple D"rimenty ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Cola Registration# License# Sticker# El Mobile Food Prep Unit--Make Vehicle Tyne Color Registration## License# Sticker# ❑ Ternporarx Food Facility---mates of operation from to ❑ Ice Plant ❑ Special'went - Dales of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Numlxr of Containers in Multi-Head Unit CUPS E] State'Facility Surcharge(2399) HAZARDOUS'%VASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------------------Tons Generated Per Year Tiercd Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(Cir) El 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 LISTA and Afprms HO SING PROGRAM(2400) 0 flotelfMotd-----Number of Units _ El Jail or Exempt fnstitutlon--Number of Unita Employee Houslag(27DO)UsB, MjZtpe"HourinZLI.ahor 4 amn,wkg i a Form 31TE MITIGATION(2900) UNDERGRWNDJNJEC7lQN CONTitOL(3000) Environmental Assessment ❑ UST-CAP Site ❑ Lotal H8V Cleanup Site ❑ NPLlSEP Cleanup Site ❑ UTC Site ❑ Abandoned RW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site IJ Water Quality Remediation Site Rfr,REATIONAL HEAL PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool 0 Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) Q Poultry Farm Maximum nurntw ofbirds ❑ Kennel TAMO. BODY PIERCING PERMANENT GO'JMETsc rrtooRAm(4100) Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) 9-1!AVID W L"'TE PR0QrtAM(4200) ❑ Pumper Vehicle—Registration# License ft Capacity Vehicle# ❑ Pumper Yard © Package Tmatmtrit Plant E3 Chemical Toilets-----Nurnber of Units SOLID WASTE PR (4400) ❑ Laadltil 0 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site 0 Waste Tire Facmty 0 Compost Facility ❑ Process/Retyele Facility ❑ CIA Landfill Site Refuse Vehicles--Number of Unitc ❑ Dumpsters>20 cu yd Number of Units E1 Farm/Ranch Cleanup Site ryIEWCAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler El Transfer Station 0 Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10-- ❑ 11 -60-----0 >60 generators PUBLIC WATER SYSTEM PRQGRAM(4600) Use PWS RYD069 Blfre Application Form E1NER6ENCY NOTIFirwriON FOR THis FACILITY ANWOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM BLVMErYrT FEE ❑ Surcharge FEL ❑ Other FEE IINSPECTOR# PERMIT VALID to ❑ F'oad Handler ❑ Check# AMOUNT PAID Date INVOICE# l ❑ Crsh RsviLrwED By ACCOUNTING OMCs Date EH 000 PrNK I`OPM doc - .a. Rev.07107/"