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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 7xdi]7�IIk�Y61 lttil_1 New EH Proaram at Facilit ID z- oO I Pro ram Record ID tQ y /L� Facility Address qOa en*ra AtVQ . SU 1ire 5 'TIrmaCaA 411537(47 (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 ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit-- Make Vehicle Type _ Registration # License #_ ❑ Temporary Food Facility --Dates of operation from to El Special Event ---Dates of operation from to DAIRY PROGRAM (2000) ❑ Multiple Departments El Prepackaged Goods Only _ Sticker # _ Color Sticker # ❑Ice Plant 13 Produce Color El Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA 1:1 Hazardous Materials Business Plan (1900) Number of chemicals: L1CalARP Program EI Program 1 Facility ❑ Program 2 Facility El Program 3 Facility 11 Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year 11 Tiered Permitting Facility -------> El CA (2232) El CE (2233, 2234, 2235, 2237) 11 PER (2231) ❑ PER HHW (2236) 11 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 11 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 11 Other CUPA Program HOUSING PROGRAM (2400) ElHotellMotel------ Number of Units 11 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 1:1 UST -CAP Site El Local HW Cleanup Site 11NPLISEP Cleanup Site 11UIC Site ❑ Abandoned HW Site Elnon-NPLISEP Cleanup Site L1RWQCB Cleanup Site 11 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) El Poultry Farm -------Maximum number of birds_ ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area 1-1 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) LIQUID WASTE PROGRAM (4200) El Pumper Landfill ❑Transfer Station 11 Stand ❑ CFO L1 ❑ B Body El Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit CUPA 1:1 Hazardous Materials Business Plan (1900) Number of chemicals: L1CalARP Program EI Program 1 Facility ❑ Program 2 Facility El Program 3 Facility 11 Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year 11 Tiered Permitting Facility -------> El CA (2232) El CE (2233, 2234, 2235, 2237) 11 PER (2231) ❑ PER HHW (2236) 11 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs 11 Underground Storage Tank Program (UST) (2300) Use UST A and B forms 11 Other CUPA Program HOUSING PROGRAM (2400) ElHotellMotel------ Number of Units 11 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 1:1 UST -CAP Site El Local HW Cleanup Site 11NPLISEP Cleanup Site 11UIC Site ❑ Abandoned HW Site Elnon-NPLISEP Cleanup Site L1RWQCB Cleanup Site 11 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) El Poultry Farm -------Maximum number of birds_ ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area 1-1 Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) LIQUID WASTE PROGRAM (4200) El Pumper Landfill ❑Transfer Station 11 Ag/Cannery Waste Site Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) �dI w� Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) El Body Art Temp Event Co-ord (4130) L1 Body Art -Temp Event Mobile Facility (4131) Vehicle Registration # L1 Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle #, ❑ Chemical Toilets ----Number of Units 11 PJVM Landfill ❑Transfer Station 11 Ag/Cannery Waste Site ❑Sludge/Ash Site El Waste Tire Facility El comp Facility ❑ ProcesslRecycle Facility ❑CIA Landfill Site 11 Refuse Vehicles (#of Units) ElDumpsters > 20 cu yd (#of Units) ElFarm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El Primary Care El Acute Care EI Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic 11 Common Storage Facility El - 10 ❑ 11-60 11> 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Biue Application Form CONTACT PERSON I^ Day P Night P - PROGRAM ELEMENT Aid.? � FEE � ei ❑ Surcha ge FEE ❑Other FEE INSPECTOR# %36 PERMIT VALID /o z Z to 630 ❑ Food Handier ElV Check# VI'54-- AMOUNT PAID 233. Date Z Z INVOICE# Co ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 ( ^ / �� 5.�� MASTERFILE RECORD I FORMATION PINK 1/23113 'J��'(,J-/M'qL/.