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.New EH Program at ExMisAtiS <br />ngTEFaRcPilliLtyE RECORD INFORMATION FORM <br />EJNew EH Program and New Facility <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Facility Address /7/7 S ()///(1). 4 S I— SAN N COUNTY <br />NEALTh ART II4 ENT <br />PAYMENT <br />poEAR <br />RYD: <br />ESNui p <br />0 No 0 <br />RECEIVED <br />'MENTAL <br />2018 <br />Commissary El Dry storage only <br />Retail Market----Square footage <br />14 Mobile Food Vehicle --Make <br />Mobile Food Prep Unit-- Make <br />Registration # <br />0 with Food Preparation <br />0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br /> <br />Vehicle Type <br />Vehicle Type. <br />License # 6,6-3 9-. s- <br />Food Handlers Course required: YES <br />Vending Machines Number of Units <br /> <br />fr. 2— Sticker # <br />Color <br />Color <br />0 Restaurant: Seating Capacity Square Footage <br />Registration # License # Sticker # <br />Temporary Food Facility --Dates of operation from to 0 Ice Plant 0 Produce Stand <br />Special Event---Dates of operation from to 0 CFO 0 A 0 B <br />Facility ID F;49,2_3Z25:3 Program Record ID a0S-7 /72-6-ME <br />SAN JOAQUIN COUNTY El\_ CONMENTAL HEALTH DEPARTI1T <br />PROGRAM ELEMENT FEE 9 Surchar e F 0 Other FEE <br /> PERMIT VALID <br />AMOUNT PAI <br />REVIEWED BY <br /> <br />to El Food Handler <br />Date INVOICE # <br /> <br />ACCOUNTING OFFICE Z • Date <br />INSPECTOR # <br />0 Check # <br />"Cash <br />DAIRY PROGRAM (2000) <br />El Grade A Dairy CI Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br />CU PA <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) > Tons Generated Per Year <br />12 Tiered Permitting Facility > 0 CA (2232) El CE (2233, 2234, 2235, 2237) 0 P B R (2231) El 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 El Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site Cl Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site El non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />0 Poultry Farm Maximum number of birds El Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />El Body Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station El Ag/Cannery Waste Site Cl Sludge/Ash Site <br />CI Waste Tire Facility I=1 Compost Facility CI Process/Recycle Facility 1:1 CIA Landfill Site <br />Refuse Vehicles (# of Units) El Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility El 2 - 10 0 ii - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON )25 Z- Day Ph Z[4 2 2,2-63?2hlight Ph <br />443-02-034 MASTERFILE RECORD I FORMATION PINK <br />1/23/13