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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />❑ New EH Program at Existing Facility Mew EH Program and New Facility <br />Facilitv ID r4(OZ7Z19) Proaram Record ID QOZ�`i75 <br />Facility Address 2.y3D f2b� k414,W XI,-QO CA- 995y /V <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 <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit— Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to <br />❑ Ice Plant <br />❑ Special Event ---Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />Produce Stand <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 />❑ 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 USTA 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 Housina/Labor 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 of birds <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 # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (#of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />❑ Ag/Cannery Waste Site ❑ Siudgel+ <br />11Process/Recycle Facility 11 CIA Landfill ,J� <br />11Dumpsters > 20 cu yd (# of Units) 11Farm/R'4*h G(ganup Site <br />% / ` 1022 <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generatglf /. ,Hauler <br />❑ Transfer Station Veterinary Clinic ❑ Common Storage Facility 2 - 10 ❑ 11 -60 <br />��d/ <br />El <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �rilfFNr <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON '�aD�.) 60 ccl; to 1(- - Day Ph -T)0 436 3t/SZNight Ph SID Q3fo 3y372 <br />PROGRAM ELEMENT FEE UV 0 ❑ Surchar e F E 11 Other FEE <br />INSPECTOR# PERMITVALID Zt0 3 Z ❑ Food Handler <br />ElCheck# AMOU-NTPAID Date : I Z' ZZ INVOICE# <br />C�C h Oogg REVIEWED BY I CAJACO ACCOUNTING OFFICE Date <br />48-0-0A /1 r�' MASTERFILE RECORD INFORMATION PINK <br />1/23/13 I l In YiU lel <br />