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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT INFORMATION FORM New I Facilitv ID Program Record ID _ Facility Address 112 971064—' OCtL 5W -IJ 61G-2VT (Please check the appropriate description and specify ssm number of units and pertinent information.) FOOD PROGRAM (1600) �-1( ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES yNo ❑ ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Vending Machines Number of Units / ❑ Vetail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only a6dgehicle -Make Vehicle Type Color �1�c Registration # License # Sticker # ❑ Mobile Food Prep Unit- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -Dates of operation from to ---tom lee Plant 13 Produce Stand ❑ Special Event --Dates of operation from to ----FCFO A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ 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 Housing/Labor Camp Application 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 ❑ non-NPLISEP 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 ❑ 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 Fi)jpcC T) LIQUID WASTE PROGRAM (4200) a Z' �C9V El Pumper Vehicle Registration # License # Capacity Vehi�QEPYEP® ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units 1 SOLID WASTE PROGRAM (4400) IIIA ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash SiteUINCOUNTY( ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA La& 6NMENTAL ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/RAPg��ryQ)�ifiB($�QiI=N7 MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM , - CONTACT PERSON YT WVI t)Nl (/Ir Day Ph Awl Night Ph %()j -01 SU • rr� PROGRAM ELEMENT�� FEE IC5 J ❑ Surcharg_e FEE _ 13 Other FEE INSPECTOR# --ft PERMIT VALID ':�4-ZV- -k t0 7 3 2 L ❑ Food Handler Oheck # L AMO NT PAID Date I NVOICE # Cash REVIEWED BY� �, ACCOUNTING OFFICE Date 48-02-034 ASTERFILE RECORD INFORMATION PINK 1123/13