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SAN JOAQUINM OUDEPARTMENT ERFILE RECORD INFORMATION FORM I PAY New EH Program at Existing Facility ❑New EH Program and New Facility RECE ��® Facility ID �2�07 � / Program Record ID 07*717h FacilityAddress 'L l So 0 % 20 �� e�. —ra..ratb. � Tt'.�.. sq 21 (Please check the FOOD PROGRAM (1 00) appropriate description and specify size, number of units and pertinent informs ion.) HSN AQUI N CO AL ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ NUNTY o tT ❑ 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 Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ 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 HousinglLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST•CAP Site El Local HW Cleanup Site ❑NPL/SEP Cleanup Site El TATTOO, BODY PIERCING, Facility -Sterilization (4121) ❑Body Generated Per Year Art -Temp Event Mobile Facility (4131) ❑ Tiered Permitting Facility ------- > ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ 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 HousinglLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST•CAP Site El Local HW Cleanup Site ❑NPL/SEP Cleanup Site El TATTOO, BODY PIERCING, Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Mobile Facility (4131) LIQUID UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Poultry Farm -------Maximum number of birds Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single Use (4120) ❑ Body Art CONTACT Day PROGRAM ELEMENT �"'� � � O FEE S a ❑ Sr INSPECTOR# �R PERMIT VALID 4 t0 ❑ Check# ' CA.I AMOUNTPAID •0V Date ❑ Cash REVIEWED BY ACCOUNTING OFFICE 1/23/13 / / wt "fl, 13 1 light Ph ❑ Other FEE ❑Food Handler INVOICE # Date 9 �� Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # 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 (# or 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 CONTACT Day PROGRAM ELEMENT �"'� � � O FEE S a ❑ Sr INSPECTOR# �R PERMIT VALID 4 t0 ❑ Check# ' CA.I AMOUNTPAID •0V Date ❑ Cash REVIEWED BY ACCOUNTING OFFICE 1/23/13 / / wt "fl, 13 1 light Ph ❑ Other FEE ❑Food Handler INVOICE # Date 9 ��