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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />IJ111I1:1c7y I4:8 7xK.1-IN -11 <br />❑ New EH Program at Existing Facility Flew EH Program and New Facility <br />Facility ID �a�2ro8,��� Proaram Record ID ?Rbs4%2.9-4, <br />Facility Address 1 W 1 J' St LIVI t,?d-,/(J <br />(Please check the appropriate description and specify size, 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 W (7Y V, hDYSe 2L` -P-Vehicle Type Color <br />Registration # License # f 2`IZ?G 2 Sticker # <br />❑ Temporary Food Facility --Dates of operation from to -EI lee Plant F-1ProduceStand <br />❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ HotellMotel----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <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 # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ <br />Cl Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/}LC,,,eanup Site <br />Small Generator ��^lIMACrydS&r <br />❑ 11 - 6060 generators <br />N� <br />cc.w..... I 0 2021 <br />`AN <br />:RAM jn.i...-. <br />CONTACT PERSON(.1Ut IlfY010 FLAfrltCS j Day Ph (90Yj)(o4Z-3235Night Ph " vIRONM v,'L <br />PROGRAM ELEMENT E3 FEE ❑ Surcharr e F E El Other FEE ENT <br />INSPECTOR# PERMITVALID 2( to 12 11Food Handler <br />❑Check # AMOUNT PAID �. Date I I2A INVOICE # v <br />N,/Cas REVIEWED BY 1 J21 AM ACCOUNTING OFFICE Date <br />40-02-034 ICV I�+__' ry_����^,--„I4 MASTERFILE REC RDI O MATION PINK <br />1/23/13 rl'�`/fN','�, �I .`fI'Il/P�"/yIXW <br />22 fr/rNr'eyou/ <br />