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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ❑ New EH Program at ID RECORD INFORMATION FORM ❑New EH Program and New ID 'Facility Address 3�12`L W N-arnmer I�n Hifi �= (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) P'4YAAENT RECEIVED MAR i 71012 �N�RONMENT NTy HEALTH DEPART NT ❑ 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 Pumper VehicleRegistration # 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 Muiti-Head Unit COPA ❑ 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 App/lcatlon 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel T TTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Facility ❑ 2 - 10 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 VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles 1# of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ FarmlRanch 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 wI:ONTACT PROGRAM ELEMENT FEE (SZ`'I" INSPecroR# PERMIT VAL ❑ Check# AMOUNT PAID ❑ Cash REVIEW ED BY 1123/13 Day Ph ❑ Su _ t0 _ Date y��L' ACCOUNTING OF2FICjE `'') '�f ��CiJ / Night Ph _ ❑Other FEE _ ❑Food Han�dl�er� _ INVOICE#moo„ Date 3 /�< MASTERFILE RECORD'INF