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NTYENV_RONM ENTAL HEALTH r SAN JOAQUINM OUERFILE RECORD INFORMTON FORM DEPARTMENT R C��NT V ' grfl1� 11 New EH Pro ram at Exletin Facility []New EHProam and New Fac1 NQV F40 Facility ID Q')2(�7� Program Record ID ski x /T ' S 0 2NO AF-acii„ty_ ddrQss 22 2 6r/GS>< re�vo✓ �E'�✓ .S�•c�o+fA uiv i of units and nerllnent information) LTy Oryry COU (Please check the appropriate description and specify Size.number -- OFp FNT Ty _ (1600) �^ Food Handlers Course repulsed: YEsya ]f] Restauran Seating Capacity 47� Square Footage ?,TUU - Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ w/Meat Market only [3 Multiple Departments❑ Prepackaged Goods Only ❑'Retail Market—Square footage ❑ Mobile Food Vehicle–Make - Vehicle Type Sticker# Registration# License# Color ❑ Mobile Food Prep Unit–Make Vehicle Type Sticker# Registration# License# ❑ Ice Plant 11 Produce Stand [I Temporary Food Facility--Dates of operation from to []CFO ❑ A O B ❑ Special Event--Dates of operallon from to l DAIRY PROGRAM(2000) { ❑ Grade A Dairy ❑ Grade B Dalry [I Milk Dispenser-Number of Containers In Mullf-Head Un t_ CUPA ❑ Hazardous Materials Business Pian(1900) Number of chemicals: ElCaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility El Program 3 Facility ❑ Hazardous Waste Generator(2200)----> Tons Generated Per Year. ❑ Tiered Permitting Facility--> ❑CA(2232) [1CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR 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) ❑ HotellMotei--Number of Unita ❑ Jail or Exempt Institution--Number of Units Employee Housing(2700) Use Emslouse HousinglLabor Cama Application Form SITE MITIGATION(2900) 1 + NpERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site , ❑ NPUSEP Cleanup Site [3 UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB 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 ❑ Kennet TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DEPS Notification (4115) ❑ Body AR FacilitySingle 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 VehicleRegistmtion# License# Capacity Vehicle# + ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(44DD) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles Is of unkn) ❑ Dumpsters>20 cu yd(a 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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46.02-003 8fue Application Form J EMERGENCY NOTIFICATION FOR s EACILITY ANoloR PROGRAM -� >�S R PROGRAM ELEMENT / n FEE ❑ Surchar FE ElOther FEE ( wzrECTOR# — OERMITVAUD 201to / ❑ Food Handler t3rc({f G - AMOUNT PAID Date ZD ?D INVOICE# —� REvewm sy AccOUNTING OFFICE (�–� Date /a01 g//2 1.29 ZgY MASTERFRE RECORD ORI,MMON PsWt