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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORD IN L�.New EH Pro ram at Existing Facilit ❑New EH Pro ram and New Facility Facility ID D 3 Program Record ID s Facility Address �� N (YI�A�I'1 tf�- (Yt(,1i1-I-2tLt C%9" �� (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 Registration # ❑ Mobile Food Prep Unit --Make Registration # ❑ Temporary Food Facility --Dates of operation ❑Special Event ---Dates of operation from Vehicle Type License #_ Vehicle Type _ License # _ Color Sticker # _ Color Sticker # _ to ❑Ice Plant ❑Produce Stand to ❑CFO Environmental Assessment ❑A❑B -CAP Site ❑Local HW 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) ---------->-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 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 App/ication 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-NPLISEP 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 ❑Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) I�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 L66La��n__dfill Site ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (#of units) ❑ Farf�FyCleanup Site MEDICAL WASTE PROGRAM (4500) Vic["'_'��wryryryry�JJJJ''"�' �f, ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑Small Generajgr LI"L"li+(IT uler ❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑ 2 -10 ❑ 11 - 6 /�/�C� > 60 ge rators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form � 20� CONTACT PERSON �6� -Q y� (G(Illy .Day Ph ~Nioht PN°�%i�� PROGRAM ELEMENT mil I � FEE sf5 ❑ Surcha ge FEE ❑Other FEE INSPECTOR# 9xt3G PERMIT VALID Z t0 � ❑ FOOd HaD� ❑Check # AMOUNT PAID � � Date 2 �%�!, INVOICE # .C.J! Cash REVIEWED BY ACCOUNTING OFFICE Date v� ,_ 48-02-034 MASTERFILE RE OR 1/23/13 PINK