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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORDINFORMA IN New EH Program at Existing Facility []New EH Proqram and New Facilitv R,6E AFD Facility ID H160)Z76(�� Program Record ID 8,1V FEB U3 2022 elAeeSdescription PINE STREET, ODlO e NEALr/ MCOUNJy(Pasetheck thappro appropriate and specifysiznumber of units and pertinent information.) D�pAE FOOD PROGRAM (1600) Rrm4r ❑ Restaurant: Seating Capacity. Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Drystorage 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 ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ElElHazardous Waste Generator (2200) ---------- >-Tons Generated Per Year El Tiered Permitting Facility -------> 11 CA (2232) 11 CE (2233, 2234, 2235, 2237) El Aboveground Storage Tank Facility (AST) (2800) Number of ASTs El Underground Storage Tank Program (UST) (2300) Use USTA and B forms 11 Other CUPA Program Program 3 Facility El PBR (2231) ❑PBR HHW (2236) 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 ❑ NPL/SEP 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 _ [I Pool ❑Spa Out Service Pool/Spa VECTOR CONTROL PROGRAM (4000) ElPoultry Farm -------Maximum number of birds ❑ of ❑Natural Bathing Area 11 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 Co -Ord (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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON AMY ACAYA Day Ph 209-815-7342 Night Ph 209-815-7342 PROGRAM ELEMENT '14110 FEE 4161 ❑Surcharge FEE El Other FEE INSPECTOR# 9834 PERMIT VALID Z t0 L El Food Handler ❑ Check#AMOUNTPAID Date 2 3 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date y 48-02-034 7/23/13 MASTERFILE RECORD INFORMATION PINK (/_,)(J...-/�-,F"'/r(