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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT INFORMATION FORM Yr] New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID )5dIDZ/o <'3 Program Record ID W>C417441 "7 Facility Address 2353 Pacmc' tjVeAwt:;e 5u1 -1a q- S{ cW�O-KfLn W104t— (Please check the appropriate description and specify size, number of units and pertinent Information.) 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 ❑ 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 Mulfi-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 ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel -----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-NPIJSEP Cleanup Site ❑ RWQC13 Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility 11 Pool [IS a VECTOR CONTROL PROGRAM (4000) 11Poultry Farm -------Maximum number of birds _ ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel \ T—ATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) YLI 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) 11 Pumper VehicieRegistration # License # Capacity Vehicle # ❑ Pumper Yard 1:1Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) El Landfill 11Transfer Station 13Ag/Cannery Waste Site ❑ SludgelAsh Site 13Waste Tire Facility ElCompost Facility ElProcess/Recycle Facility ❑ CIA Landfill Site 1:1Refuse Vehicles (a of units) ElDumpsters > 20 cu yd (s of units) EIFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) [IPrimary Care 11Acute Care ❑ Skilled Nursing ElLarge Generator 11Small Generator ❑ Limited Hauler 11Transfer Station 1:1Veterinary Clinic 11Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form CONTACT PROGRAM ELEMENT �I 11(1 FEE a a ❑ SI INSPECTOR# PERMIT VALID i 22 t0 ❑ Check# AMOUNTPAID L146D Date ❑ Cash REVIEwrD ay ACCOUNTING OFFICE 48-02-0 34 1/23113 CON F- � 137511,551 Night Ph 20 9 � 4 Ol � 3 2$Z-- _ ❑Other FEE _ ❑Food Handler _ INVOICE# S7 Date TfW MASTERFILE RECORD MF Form CONTACT PROGRAM ELEMENT �I 11(1 FEE a a ❑ SI INSPECTOR# PERMIT VALID i 22 t0 ❑ Check# AMOUNTPAID L146D Date ❑ Cash REVIEwrD ay ACCOUNTING OFFICE 48-02-0 34 1/23113 CON F- � 137511,551 Night Ph 20 9 � 4 Ol � 3 2$Z-- _ ❑Other FEE _ ❑Food Handler _ INVOICE# S7 Date TfW MASTERFILE RECORD MF 34 1/23113 CON F- � 137511,551 Night Ph 20 9 � 4 Ol � 3 2$Z-- _ ❑Other FEE _ ❑Food Handler _ INVOICE# S7 Date TfW MASTERFILE RECORD MF Night Ph 20 9 � 4 Ol � 3 2$Z-- _ ❑Other FEE _ ❑Food Handler _ INVOICE# S7 Date TfW MASTERFILE RECORD MF