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PA UNTY NTAL SAN JOAQUINMAORECORD M�oRMa HEALTH1DEPARTP�IENT STERFILEFORM R C ryNT ON O _ F ❑ New EH Program at Existing Facility _ ❑New EH hrociram and New Facility AN 1 Facilit IDbD 003 Program Record ID� 3 `OAQ 20�s HRovU"t COVr Facility Address11 1 ZL�I'b4'�vLf"ILCr �Y,�C , ��C`r�cry �t;✓L1 C' r �I`� �; e (Please check the approprlatt:description and specify slzg, number of units and pertinent informal) ) FOOD PROGRAM(1000) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required; YES 122 i'la L7 ❑ Commissary ❑ Dry storage only ❑ with Food Preparatiun ❑Vending Machines Number of Units _ 0,,,Retail Market---Square footage ❑w/Mast Market only El Multiple Department El Prepackaged Goods Only Ods AAobile Food Vehicle--Make LV C� 1 c.:�fC _ Vehicle Type L((l�4 Lft,`CColor 1.--• _ / Registration# License# (�VO 4g1W _ Sicker# - — 9 Mobile Food Prep Unit--Make Vehicle Type _ Color____ Registration#_ Lcense# _ _ Slicker# _ 11Temporary Food Facility--Dates of operation from _ to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from _ _ to _ _ ❑ CFO ❑ A ❑ 6 DAIRY PROGRAh1(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ' ❑ Program 1 Facility ❑'Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility- ---> ❑CA(2232) ❑ CE(223:3.2234, 2235.2237) ❑ PBR(2 231) ❑ 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 PROGRAfd(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exompt Institution---Number of Units Employee Housing(2700)Use Emnlovee Housing/tabor Camp Application Farm SITE MITIGATION(2900) UNDERGROUNDLNJFCTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Sitc ❑ Local HW Cleanup Site ❑ NPUSEP C eanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ W ter Quality Remedlatian Site RECREr\T ONAL.HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Cut 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(41 10) ❑ Mechanical DSPS Notification(41 15) ❑ Body Art Fa ility-Single Use(4120) ❑ Body Art Facility-Sterilization(412 1) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Ternp Event Mobile Facility(4131) LIQUID`HASTE PROGRAM(4200) ❑ Pumper VehicleRegisiration# _ License# _ 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 P or un Is) _-_ ❑ Dumpsters>20 cu yd(sof unas)__ ❑ Farrn/Ranch Cleanup Site MEDICS WASTE PROG (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 WAIR SYSTEM PROGNAtA(4600) Use PWS EHD 46-02.003 Blue Appllcatiorr 1-orm EMERGENCY NOTIFICATION FOR THIS F ILITY AND/0 RAM CONTACT PERSON c�_( !L— Day p L L• i �t (. f�lig t Ph 1 PROGRAM ELEh1ENr1i✓�� FEE_ i_ ❑ SUfChar(3 FEE _ ❑ Other FEE _ !FlSYFCTOrir♦ � — PERMII VALID_VALID_! — to3/ /S� ❑ Food Hancller._ C1 Check I5�- AMO PIT AID S6?) Date 161` 57- IN OICE# – —---— — ❑ Cash REVIEWED BY ACCOUNTING OFFICE t@ j 48.02.0 4 MAST RFILE PECOK0 INFORMATION PINK