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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORD INFORMATION ❑ New EH Program at Existing Facility WONeW EH Proaram and New Facility Facility ID DQ Pro ram Record ID A9FHr Facility Address �n �52vC (Please check the appropriate description and specify size, number of units FOOD PROGRAM and pertinent information.) 1441 (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Drystorage only 11 with Food Preparation Food Handlers Course re uire �rr� 04WElCommissary ❑Vending Machines Num beer MsjR '/Nc ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackage 0{ZIv' ❑ Mobile Food Vehicle -Make Vehicle Type Calor FNr Registration # License # Sticker # ❑ Mobile Food Prep Unit- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -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) ❑ PER (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 ❑ NPL/SEP Cleanup Site ❑ 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 ❑ 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 (not 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 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 1EMER ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON i- ,, I Day Ph `l-`l7o`fJ6 Night Ph ow7'`f PROGRAM ELEMENT FEE ❑ Surch ge F E ❑ Other FEE INSPECTOR# PERMIT VALID to 113 - 1 ❑ Food Handler ❑ Check # AMOUNT PAID i Ol] Date 1.Z INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 2� 48-02-034 MASTERFILE R COR INFORMATION PINK 7/2313 (z 4 87SY117)-