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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ❑ New EH Program at Existing Facility I�New EH P�ro7gram and New Facility Facility ID -� �r//Sli Program Record ID i�AC-µ'7I Facility Address 11_S' N � M�A�1 `�'C1(gP1` 1J1GVIt'eC/.� lid t'�.�31 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) R�cF ��O SAN FFQ' � 1�?7 HSA rN p PARTM CNry ❑ Restaurant: Seating. Capacity _ Square Footage Food Handlers Course required: Yes ❑ No�i ❑ Commissary ❑Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ wlMeat Market only ❑Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type. Color (4121) 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: ❑ 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 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 Houslng/Labor Camp Application Fonn SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑UST -CAP Site ❑Local HW Cleanup Site ❑NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number ofPools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑ Spa ❑ Out of Service Pool/Spa ❑Natural Bathing Area TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ 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 Dumpsters > 20 cu yd (# of units) 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) MASTERFIL�ORMATION ❑ Landfill ❑Transfer Station ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles t# 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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn CONTACT PERSON �1 Day Ph PROGRAM ELEMENT H I�,Ib FEE C ❑ Si INSPECTOR# PERMIT VALID Z t0 ❑ Check #___ AMOUNT PAID .� DatE ❑ Cash REVIEWED eY ACCOUNTING OFFICE 7/23173 /3S �� 3� Ph ❑Other FEE ❑Food Handler/ INVOICE # 36-T Date 2//%/�Z MASTERFIL�ORMATION PINK