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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Facility ID j:7 ( ; <br />Facility Address <br />RECORD INFORMATION FORM <br />Record ID <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License #_ <br />❑ Mobile Food Prep Unit-- Make Vehicle Type _ <br />Registration # License #_ <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />13Multiple Departments 1:1Prepackaged Goods Only <br />L <br />Color <br />Sticker # <br />_ Color <br />Sticker # <br />_ ❑ Ice Plant El Prod <br />CFO ❑A❑B <br />Stand <br />11 Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200)---- ------ >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (22331 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution --•-Number of Units <br />Employee Housing (2700) Use Emp/oiHousing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ 11 Pool <br />In "I <br />VECTOR CONTROL PROGRAM (4000) <br />1:1Poultry Farm -------Maximum number of birds <br />❑Spa ❑Out of Service Pool/Spa ❑Natura <br />Area <br />11 <br />Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Alt Facility -Single Use (4120) <br />[]Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Ve MiMENOT <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units�+ <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/As SO ZQ2� <br />11 Waste Tire Facility 11 Compost Facility ElProcess/Recycle Facility El CIA Lartp�IPSNe <br />❑ Refuse Vehicles (#ofunits) ❑ Dumpsters> 20 cu yd (#ofunits) ❑ Farm/RaEncNVfl MQP KV <br />MEDICAL WASTE PROGRAM (4500) SANXL <br />ARTMENT <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator C{l(,kWTt��auler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02003 Blue Application Form <br />CONTACT <br />Day Ph <br />PROGRAM ELEMENT VIII d FEE d � rt ❑ St <br />Ph <br />INSPECTOR# 9$3,L1 PERMIT VALID �t0, <br />❑ Check# V1 Al , AMOUNT PAID 52Date <br />❑Cash <br />REVIEWED BY <br />OFFICE <br />1/23/13y (V <br />e F ❑Other FEE <br />� ❑Food Handler <br />b�L INVOICE# t° <br />/ Date / <br />