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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORD INFORMA ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 'FA Oro 2 -Li Program Record ID 4Q Facility Address 1-1 l� S U V (l DAA Cl, 6f 520-0 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ etail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle –Make Vehicle Typ�gg Color Registration # License # c l Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Colo 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 ❑ Hazardous Waste Generator (2200) ------ --->-Tons Generated Per Year ❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor 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-NPLtSEP 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 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 Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) �p� ❑ Pumper Vehicle Registration # License # Capacity PAtYe1190T ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number FRNED — SOLID WASTE PROGRAM (4400) '7 �j 11 Landfill 11 Transfer Station ElAg/Cannery Waste Site ❑ $JR&I.4 ls00 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA L AIbI*N ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# or units) INp Site MEDICAL WASTE PROGRAM (4500) HEALTH DEPARTME ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 -10 ❑ 11 -60 ❑ > 60 generators CONTACT (4600) Use PWS EHD 46-02-003 Blue EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Day Ph Night Ph PROGRAM ELEMENT I� FEE - ❑ Surchar a FEE 11 Other FEE INSPECTOw # S PERMIT VALID to ( ❑ Food Handler ❑ &$W 7, 11-�ICAMOUNT PAID �Z'J — Date 2iI7 INVOICE# ❑ Cash REVIEWED BY NVV ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFtORMATION PINK 1/23/13