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-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Facilitv ID 77--4^A 2J,/_-7 7 Proaram Record ID <br />FacilityAddressXlGLIO WA)VUSt, Dfwiyff,c/1 GkW` 1 <br />(Please check the appropriate description and specify sgM number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market --Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit— Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility —Dates of operation from to ❑ i Plant ❑ Produce Stand <br />[3 Special Event—Dates of operation from to CFO L� A ❑ B <br />rPR OGRAM (2000) <br />de A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit _ <br />COPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -->-Tons Generated Per Year <br />❑ Tiered Permitting Facility --> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee HousinatLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility — ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm —Maximum number ofbirds <br />— <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/ Site <br />❑ Waste Tire Facility 13Compost Facility 13Process/Recycle Facility ❑ CIA l �E <br />❑ Refuse Vehicles I# of units) ❑ Dumpsters > 20 cu yd (# of Units) [3 Farm lea eits <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care 13Acute Care ❑ Skilled Nursing ❑ Large Generator 13Small Generator 4yfoftd Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 6§ANJQ > 60 geriaitors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form y E�RQU/NC <br />^_EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMR/D NNrR N7y <br />CONTACT PERSOtJL V I Q `I ki Day Phi -Gj Night Ph qSQ <br />PROGRAM ELEMENT q 16D'6 FEE ❑ Surcha a ❑ Other FEE <br />INSPECTOR# PERMITVALID to 7 /FE ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # 35 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date % <br />4802-034 VMASTERFILE RECORD INFORMATION PINK <br />1123113 IZ �^I <br />