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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />!t RECORD INFORMATION FORM <br />II Facilitv ID i AUU Z / 552— Program Record ID rKQS �+ /`7 i - V <br />,OFacilityAddress-*t-i`>>I I�NUt <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 />Tnl,Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />❑ Retail Market ---Square footage LIw/Meat Market only ElMultiple Departments ❑ Prepa aged Goods Only <br />I�Mobile Food Vehicle—Make V.l Y,\ Vehicle Type Color �i'V I Ou, 1,6, , <br />l 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 ❑ Ice Plant ❑ Produce Stand <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 ❑ Program 3 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 />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 Housing/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 ❑ 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 # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Slud(��N% <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA ttevve--"�++ <br />❑ Refuse Vehicles (#of unus) ❑ Dumpsters > 20 cu yd (#of units) ❑ Farmc/Raanc�lEif� Site <br />MEDICAL WASTE PROGRAM (4500) SEPI n' <br />EI Primary Care 11 Acute Care El Skilled Nursing El Large Generator ❑ Small GeneraW 11Li m iie4' filer <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60�%tors <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACTPERSON <br />R THIS FACILITY AND/OR PHUGR M / -�"AWr/i -O <br />Day Ph � f0 (rj-A- IbSNight Ph 5 L4.'�' 7 / / to — Y �f <br />PROGRAM ELEMENT 35 FEE2 nom^ 11Surchar e F E ^ 11 Other FEE <br />INSPECTOR# (�.� PERMITVALID �1 I�-• FL% t0 2 �` ❑ Food Handler <br />El Check # AMOUNT PAID i . Date AA 12 Z2J INVOICE# 7 3� <br />L7 tspfsh \))� REVIEWED13Y ACCOUNTING OFFICE I'�A Date Z.$S�ZZ- <br />a <br />