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LTH SAN JOAQUINM COUNTY ERFILE RECORD INFORMATION A DEPARTMENT FORM ❑ New EH Program at Existing Facility &New EH Program and New Facility 460, Facility ID F 60 2-73� 3rogram Record ID �QSy7� 3qN✓ Facility Address1_l D of Ya h �/ 33aFq�N�R Q0i ?O�Z (Please check the appropriate description and specify size, number of units and pertinent information.) ryOFp�F,yO� FOOD PROGRAM(1600) qq /gRTM�<�TY Res'�taurant: Seating Capacity V Square Footage V Food Handlers Course required: YES® No ❑ �T ❑ 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 Registration# License# Slicker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Slicker# ❑ Temporary Food Facility--Dales 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 Facil ty ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Ton,Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2237) ❑ PER(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) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing (2700) Use Employee HousinWLabc•r Camp Application 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-NPL/SEP 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 TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Arf Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# _icense# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#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 Form Sl nn EMERGENCY NOTIFICATION FOR THIs FAC ITY AND/oR PROGRAM - CONTACT PERSON M b Ah" Day Ph 20� ,S ODY Night Ph 5 PROGRAM ELEMENT 1\C,1 y FEE p ❑ Surchar a FE ❑ Other FEE INSPECTOR# �� PERMITVALID o �I 22 t0 � Food Handler ❑ Check p _- El PAID 00 Date $ �� Zz- INVOICE# .36 gffS k ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 11231103A W. ,/} /� "l/ 7D3 MASTERFILE RECORD INFORMATION PINK