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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Mew EH Program and New Facility Facility ID �ia/S/� 2%��l Program Record ID {PIRDS4F07-7-- REC,Ej OCT 191022 SgNOR4UNC HEgCTH, pC�NMEN?UNry Facility Address �I ODy e (� ti2 Q . 'So, -r\ rro`nC t Sc 6PARvr` N (Please check the appropriate description and specify size, number of units and pertinent Information.) 9 -A FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -Dates of operation from to -13 Ice Plant 11Produce Stand ❑ Special Event—Dates of operation from to 11CFO ❑ 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) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of AST$ ❑ 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 ❑ NPUSEP 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 Coord (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 (# of 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 112 - 10 ❑ 11-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form aA� ".L ,. �,, 6 jo 352 3£72 CONTACT PERSON Daayy P Ph 5 l0 r -t'76 S8� Night Ph PROGRAM ELEMENT `�y 1 FEE 26+ ^ ❑ Surcharge FEE ❑ Other FEE INSPECTOR # L'% 1 \ar PERMIT VALI 1 • \G' 2 2- to \ l�I ' .3 ' 2 2) ❑ Food Handier ❑ Check # � AMOUNT PAID , 00 Date / INVOICE # [ ❑ Cash REVIEWED 9Y ACCOUNTING OFFICE Date ZD ZZ 1r23113 n /,-/ 4 /� MASTERFILE RECORD INFORMATION PINK ueyfa (/ CJ�IYII