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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECORD INFORMATION 4=.PIeW EH Program at Existin Facility ❑New EH Program and New Facility A ,9� FacilitylD ��a-1/1 Program Record ID Q[�S�%�0�� NY•9 Facility Address j l Z �1 U v; �t s 4� a � C4 S �34�7 / F� (Please check the appropriate description and specify size, number of units and pertinent information. FOOD PROGRAM (1600) )-(, 40�2 ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course re Rp,{-., No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of •yMFNa_TV ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged S iQnly ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # ❑ Mobile Food Prep Unit•- Make Registration # El Temporary Food Facility --Dates of operation from El Special Event ---Dates of operation from DAIRY PROGRAM (2000) 11 Grade A Dairy IJ Grade B Dairy License # Sticker # Vehicle Type Color License # Sticker # to 1:1Ice Plant 11Produce Stand to 11 CFO ❑A❑B ❑ Milk Dispenser -Number of Containers in Multi -Head Unit COPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility EI11Hazardous Waste Generator (2200) ---------- >-Tons Generated. Per Year 11 Tiered Permitting Facility -------> El CA (2232) ❑ CE (2233, 2234, 2235, 2237) EI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs EI 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 Housfno/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-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 TATOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilitySingle 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) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill 11 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 1:111 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02403 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM r CONTACT PERSON r'� t V� P Z 01 )� 2.5--S�ONight Ph 205) PROGRAM ELEMENT_ *Y110 FEE d 16 P2 ❑ Surchar e FSE ❑ Other FEE INSPECTOR # 9 R 3 (( PERMIT VALID ty13122, toIJFood Handler ❑Check# AMOUNT PAID(J •OD Date INVOICE# 3 b 44Cash REVIEWED BY ACCOUNTING OFFICE Date / 2Z 6 MASTERFILE RECORD INFORMATION PINK