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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />LE RECORD INFORMATION F( <br />Cff New EH Pro ram at Existing Facility EI New EH Program and New Facility <br />Facility ID & ()O2:;9qD Program Record ID <br />Facility Address-20044&�- ti in 619,L0S <br />(Please check the appropriate description and specify s e, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market --Square footage ❑ w/Meat Market only <br />obile Food Vehicle—Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event ---Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Vehicle Type <br />License # <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />-S-ticker <br />Color <br />Sticker # _ <br />Vehicle Type Color _ <br />License # 1AftA 2Z Sticker # _ <br />to ❑ Ice Plant <br />to El CFO ❑A❑B <br />Produce Stand <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP 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 />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housino/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-NPUSEP Cleanup Site ❑ RWOCB 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 ❑ 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/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) !��f4Rmi <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limit I�4 <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑2 - 10 ❑ 11-60 ❑ > 60 gen <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form /�'! Q <br />RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM J.1/l,1101,1Q,", <br />,`3?O <br />CONTACT PERSON Day Ph - 3 Night Ph F Oq0 2% <br />PROGRAM ELEMENT � � FEE ❑ SurchairqeFEE 11 Other FEEHDfp�, FI1"A,NjY <br />INSPECT R# PERMITVALID to Z 2J ❑ Food Handier <br />❑ AMOUNT PAID Date INVOICE # 2 <br />❑ Cash l: REVIEWED BY IAIA 07 S. ACCOUNTING OFFICE PAM Date p2 W <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />