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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT INFORMATION ❑ New EH Program at Existin Facilit L9�New EH Program and New Facility Facility ID ab2-( DZ Program Record ID Facility Address 0321 �AGt.�t[; VQ• S�GCk.1-G�1 C!-� �G�- (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) R��F AFD SfP 2) ?�21 SAN � IR QUI HEALTH p PgRTM�Nyry ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑Dry storage only ❑ v✓ith Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑Multiple Departments ❑Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color ❑CIA Landfill Site Registration # License # Sticker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color 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-Numberof Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Numberof chemicals: ❑ CaIARP Program ❑Program 1 Facility ❑Program 2 Facility ❑Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Numberof ASTs ❑ Underground Storage Tank Program (UST) (2300) Use LISTA and 8 forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel------Numberof Units ❑Jail or Exempt Institution ----Numberof 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) 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) ❑ Pumper Vehicle Registration # ❑ Pumper Yard License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Numberof 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 of Units) ❑ Dumpsters > 20 cu yd (a of units) ❑ FarmlRanch 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 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PROGRAM ELEMENT 4IIO FEE INSPECTOR # G► 7�(�3 PERMIT VAL Check# /�Cd�— AMOUNT PAID Cash REVIEW ED BY 7@3/13 �- ❑ SI I to D Date ACCOUNTING OFFICE Night Ph ❑Other FEE _ ❑Food Handler _ INVOICE#� Date MAS7ERFILE RECOROtINF PINK