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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT INFORMATION FORM I)`J New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Landfill Program Record ID QZ Y7;ZI 41, IV Facility Address�lAZ C wo`v�w6 UkvE, 8AIVj V 02 2021 (Please check the appropriate description and specify size, number of units and pertinent Information.) fv RQN/ry COUN FOOD PROGRAM (1600) E1lTH �" 11 Restaurant: pEPgENpqL Seating Capacity Square Footage Food Handlers Course required: YEsPLMEftI� El ❑ 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 Registration # ❑ Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility --Dates of operation ❑ Special Event ---Dates of operation from Vehicle Type Color License # Sticker # Vehicle Type License # to to Calor Sticker # ❑ Ice Plant ❑ Produce Stand ❑CFO ❑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) ---------- ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 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 El Local (4400) >-Tons Generated Per Year ❑ Landfill ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (22333 2234, 2235, 2237) ❑ PBR (2231) ❑ PER HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 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 El Local RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ TATTOO. BODY PIERCING, ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) 'Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification k4 v) ❑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# ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill 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 ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ TATTOO. BODY PIERCING, ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) 'Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification k4 v) ❑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# ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill El Trans Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh 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 1:12 -10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form .cT �MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON y�\��\ \\\e u2U� Day Ph �I0' j2 ' C,jNight Ph PROGRAM ELEMENT N I I D FEE >� J ❑ Surchar a FE ❑ Other FEE INSPECTOR# 9534 PERMIT VALID t0 � � y ❑ Food Handler Check # AMOUNT PAID .6 Date INVOICE # .91q:3 fYJ Cash REVIEWED BY ACCOUNTING OFFICE / Date / ,�12