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SAN JOAQUIN COUN'lY ENVIRUNNIEMAL 11LALIII DLI'AR I MEN F :Vl 4ew EH Proeram at Existing Facilitv ❑New EH Program and New Facilitv Facility Address 22-4-�G (Please Check the appropriate description and specify FOOD PROGRAM (1600) Record ID number of units and Pertinent information.) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Mobile Food Vehicle -----Make Registration # ❑ Mobile Food Prep Unit --Make Registration 0 ❑ Temporary Food Facility -----Dates of operation ❑ Special Event --Dates of operation from from Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines —Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Vehicle Type Color License # Sticker # Vehicle Type License # _ Color Sticker # to ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste �• 2g �ABOVECROUND STORAGE TANK FACILITY (AST) (2390) Number of AST �Z UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms 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 ❑ NPLJSEP 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 TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units SOLID WASTE PROGRAM (4400) Cl Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number 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 ------- ❑ 11 - 60 ------ El > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIPS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph 2%;' — 9.-35_Night Ph PROGRAMELEMENT ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 44 36 PERMIT VALID �?l /� to 2-1—i1— ❑ Food Handler ❑ Check AMOUNT PAID Da[e / INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Q 48-02-034 Masterfile Record Pink 11/18/03