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EIDE p SAN JOAQUIN COUNT LEENVIRON RECORD NFNTAL HEALTH DEPARTMENT PR O, ?021 STERIID aw EH Program and New ! I)A ❑New EH Program at Existing Fact If _ � it QUlfy CO /� /MEa r L R1 U Faelllty ID �J�� ,�,�rOBram Record ID int - C� H��TTA�Ty Facility Address 3 e 0 i �(�� MENT (Please check the appropriate description and specify aid number of units and Q9I! Cr41tl_91U) f� FOOD PROGRAM(ieali �(,� / Yes No❑ Square Foote e J 6 r s Food Handles C#urae raoulred• Restaurant Sealing Capacity B on ❑Vending Machines Number of Units ❑commissaryrke ❑Dry re footage only ❑with Food wlMeot Ma ❑Retell Market—Square fogteBe ❑wlMeal Markel only ❑ Multiple Departments❑ prepackaged Goode Only Vehicle Type Color 11 Mobile Food Vehicle--Make License# Slicker if Reggistration# Color ❑Mobile Food Prep Unit..Meka Vehicle Type Registration# License# Slicker If to E3 Ice Plant 13 Produce Stand ❑Temporary Food Facility Drape of operation from. ❑ CFO El A 13 B ❑Special Event–.Dates of operation from to DAIRY PROGRAM(21100) ❑Grade A Dalry ❑ Grads B Dalry ❑ Milk Dispenser-Number of Containers in Mulll-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) ❑ 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) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution--••Number of Units Employee Housing(2700)Use Employee Houslno/Labor Camp Aoolicallon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑,rton-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediatlon Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ 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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICAT107 FOR THIS FACT ITY AND/OR PROGRAM CONTACT PERSON Day Ph Z It Night Ph PROGRAM ELEMENT /G�2. 3 FEE Q--� ❑ Surchar e FEE ❑ Other FEE INSPECTOR III PERMIT VALID 7 2'41 - to `t ❑ Food Handler 13 Check# I --- AMOUNT PAID - •(�(� Date INVOICE# ❑ Cash RE%nBvEDeY ACCOUNTING OFFICE Date '?IZ 4e-02.034 ;1 i MASTERFILE RECORD INFORMATION PINK 1123113