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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />❑ New EH Pr ram at Existing Facility ❑New EH Program and New Facility <br />I e...uu„ In t7 t:�1.: �. j `f.: Proararn Record ID :-„ <br />Facility Addressqs ` nC V.` oe\P V -n& �/� <br />(Picase check the appropriale description and specify size, number of units and pertment information.) <br />FOODPROGRAM(1600)�j <br />L�.Restaurant: Sealing Capacity--�4 SSquare Foofage26�o SF • Food Handlers Course required: YeaZlNo ❑ <br />0 Commissary 0 Dry storage only 0 with Food Preparation ❑Vending Machines Number of Units <br />0 Retail Market—Square footage D w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />0 Mobile Food Vehicle—Make Vehicle Type _ <br />Registration # License # <br />0 Mobile Food Prep Unit• -Make Vehicle Type <br />— <br />Registration # License # _ <br />0 Tem ora Food Facilil —Dates of operation from to <br />_ Color <br />Sticker # <br />Color _ <br />Sticker # <br />P ry y D Ice Plant 0 Produce Stand <br />0 Special Event—Dates of operation from to Z3 CFO 0 A 0 B <br />DAIRY PROGRAM (2000) <br />0 Grade A Dairy 0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />0 Hazardous Materials Business Plan (1900) Number or chemicals: <br />D CaIARP Program 0 Program 1 Facility D Program 2 Facility 0 Program 3 Facility <br />D Hazardous Waste Generator (2200) --->-Tons Generated Per Year <br />0 Tiered Permitting Facility—> 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) D PBR (2231) D PER HHW (2236) <br />0 Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />D Hotel/Motel—I, umber of Units 0 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 />0 Environmental Assessment 0 UST -CAP Site 0 Local HW Cleanup Site 0 NPUSEP Cleanup Site 0 UIC Site <br />D Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remo i�,? 9 &T <br />RECREATIONAL HEALTH PROGRAM (3600) RECEIVED <br />Number of Pools/Spas at Facility _ 0 Pool 0 Spa D Out of Service Pool/Spa 0 Naturaap n� J <br />Area <br />VECTOR CONTROL PROGRAM (4000) 61 t 2022 <br />D Poultry Farm ---Maximum number of birds 0 Kennel <br />icnrnuv� vnnr <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />1•f.,1LiII IIL1Al<1lAF i.l <br />D Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art FacilitySingle Use (4120) <br />0 Body Art Facility -Sterilization (4121) D Body Art Temp Event Coord (4130) 0 Body Art -Temp Event Mobile Facility (4131) <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Wr'CONTACT PERSON .e C, Day P ight Ph —ZLA H:Z 1S 3 2 � <br />PROGRAM ELEMENT EE ❑ Surchprge F E ❑Other FEE <br />INSPECTOR # - PERMIT VALID ) G 1 <. 2 �— 10 0 Food Hand�lJer <br />D Check # f (4. AMOUNT PAID Dale I �� }I i/L-' ! /—i VOICE # / "� 7 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Dale 2- <br />4"1434I 434:4347<�✓ as MASTERFILE RECORD INFO TI N PINH <br />1123413 J�-:- 1 51 , �_, <br />WASTE PROGRAM (4200) <br />FLIQUID <br />D Pumper VehicleRegistratlon # <br />License # Capacity <br />Vehicle # <br />0 Pumper Yard D Package Treatment Plant D Chemical Tollets <br />—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />0 Landfill 0 Transfer Station <br />0 AglCannery Waste Site <br />0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility <br />0 Process/Recycle Facility <br />0 CIA Landfill Site <br />0 Refuse Vehicles (#of uou,)_ <br />0 Dumpsters> 20 cu yd (# of uoa„ <br />❑ FarmlRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />0 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator ❑ Small <br />Generator 0 Limited Hauler <br />D Transfer Station 0 Veterinary Clinic <br />0 Common Storage Facility 0 2 - 10 <br />D 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />Wr'CONTACT PERSON .e C, Day P ight Ph —ZLA H:Z 1S 3 2 � <br />PROGRAM ELEMENT EE ❑ Surchprge F E ❑Other FEE <br />INSPECTOR # - PERMIT VALID ) G 1 <. 2 �— 10 0 Food Hand�lJer <br />D Check # f (4. AMOUNT PAID Dale I �� }I i/L-' ! /—i VOICE # / "� 7 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Dale 2- <br />4"1434I 434:4347<�✓ as MASTERFILE RECORD INFO TI N PINH <br />1123413 J�-:- 1 51 , �_, <br />