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ENVIRON NTAL HEALTH SAN JOAQUINM COUNTY REcoRD INPORMAT oN FDRMDEPARTMENT /1 CtM�Nr ❑ Nr=jew EH Pro rem of Exlstlnil Facility ONew EH Pro mm and Now Facility Jvnl Facllit ID CX�2��-� Program Record ID /Z L SA1V ,10 Facility Address � A 13 w 7 M Fe ewe . t yiy cT CA ctS' crV RO/V cobN ,. (Pleas check the appropriate description and specify s ze, number of unite and perOnen! Information.) �FPq ��NTAC ) FOOD PROGRAM (1800) M�jvY 0 Restaurant: Sealing Capacity_ Square Footage Food Handlers Course reaulred: YES 0 No 0 0 Commissary 0 Dry storage only 0 with Food Preparation ❑Vending Machines Number of Units 0 Retail Morket—Square footage 0 w/Meat Market only 0 Multiple Departments O Prepackaged Goods Only 0 Mobile Food Vehicle –Make Vehicle Type Color Registration # License # Slicker # ❑ Mobile Food Prep Unit– Make Vehlcle Type Color . Registration # License # . Stickerill 0 Temporary Food Facility –Dales of operation from to 0 Ice Plant 0 Produce Stand 0 Special Event—Dales of operation from to 0 CFO 0 A 0 B DAIRY PROGRAM (2000) 0 Grade A Dalry 0 Grade B Dalry 0 Milk Dispenser -Number of Containers In Multi-Head Unit _ N O- UP9 0 Hazardous Materials Business Plan (1000) Number of chemicals: 0 CaIARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility 0 Hazardous Waste Genamtor (2200)—> -Tons Generated Per Year 0 Tiered Permitting Facility —> 0 CA (2232) 0 CE (2233, 2234, 22353 2237) 0 PBR (2231) 0 PER HHW (2236) 0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 0 Underground Storage Tank Program (UST) (2300) Use UST A and a forms 13 Other CUPA Program HOUSING PROGRAM (2400) 0 HoteNMotel —Number of Units 0 Jail or Exempt Institution —Number of Units Employee Housing (2700) Use Employee HouslnalLabor Cama Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) 0 Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site 0 Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Slte 0 Water Quality Remedlatlon Site RECREATIONAL HEALTH PROGRAM (3600) Number of PooWSpas at Facility _ 0 Pool 0 Spa 0 Out of Service P0011Sp2 0 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) 0 Poultry Farm —Maximum number of birds 0 Kennel 41tT ody E C PROGRAM (4100) Bonor Reg (4110) 0 Mechanical DEPS Notification (4115) g' rd y Art FacllltySingle Use (4120) 0 Body Art FacllltyStcrllizatlon (4121) 0 Body Art Tamp Event Coord (4130) 0 Body Art-Temp Event Mobile Facility (4131 ) LIQUID WASTE PROGRAM (4200) 0 Pumper VehlcleRegistration # License ltCapacity Vehicle # O Pumper Yard O Package Treatment Plant O ChomIcRI Toilets —Number of Units SOLID WASTE PROGRAM (4400) 0 Landfill 0 Transfer Station O AglCannery Waste Site 0 Sludge/Ash Site 0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site O Refuse Vehicles (solunits) ODumpsters > 20 eu yd tK of units) _ O FarnVRaneh Cleanup Site I MEDICAL WASTE PROGRAM (4500) ❑ Primary Care 0 Acute Care 0 Skilled Nuking 0 Large Generator ❑ Small Generator O Limited Hauler 0 Transfer Station 0 Veterinary Clinic 0 Common Storage Facility O 2 - 10 0 11 - 6o 0 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Appllca#on Form EMERGENCY N T FICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON U I NwA .i Day Ph �I -.1 Night Ph PROGRAM ELEMEN1 40 11 � FEED Stitcher a FEE 0 Other FEE fVp INSPECTOR #,r ci�Yi �� L�- PERMIT VALID � IO � 30 ❑ Food Handler ' 0 Checkit! AMOUNT PAID z3 Date INVOICE # 0 Cash REVIEWED BY ACCOUNTING OFFICE Date i7 { , ^ MASTERFIM RECORD INFORMATION PINK 3J/ 1/23/13 If/ I /Z4 ` f'8 �7 �3(ob rz3/1 �n _