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SAN JOAQUIN COUNTY <br />EH Program at <br />Facility ID C21no <br />Facility Address <br />AL HEALTH DEP <br />El New EH Pro am and New Facility <br />�d ID - OS2'y7 D I <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) - <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Courserequired: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Vending Machines —Number of Units <br />❑ Retail Market. ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type <br />Registration # <br />License # <br />❑ Mobile Food Prep Unit --Make <br />Vehicle Type <br />Registration # <br />License # <br />❑ Temporary Food Facility -----Dates of operation from <br />to <br />❑ Special Event --Dates of operation from - <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recycl`ers (2217) <br />Tiered Permitting Facility---------- ❑ Conditionally Authorized (CA) ❑ Conditionally. Exempt{CE)' <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />.ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST / 1 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM -(2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) - <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -----Number of Units <br />Employee Housing (2700) Use Employee HousinelLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RW_ QCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa _ ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds <br />TATTOO BODY PIERCING. PERMANENT �CdSMETIC PROGRAt4(4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM 4200) <br />❑ Pumper Vehicle --Registration # License <br />❑ Pumper Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Kennel <br />❑ Piwmanent Cosmetics (4122) <br />Capacity Vehicle # <br />ff Chemical Toilets -------Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator - ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 112-10 ------- 011-60 ------❑ > 60 general - <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-01-003 Blue Application Form _ �� ^ <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night P: <br />PROGRAM ELEMENTZZ.490 FEE ❑ Surcharge FEE ❑ Other FEE_ <br />INSPECTOR# 0-4,42-3 PERMIT VALID �a-: „,.,, to ❑"Food Handler <br />❑ Check # AMOUNT <br />❑ Cash REVIEWED BY Wyll� <br />48-02-034 <br />10/6/2003 <br />Date <br />ACCOUNTING OFFICE <br />INVOICE # <br />Masterfile Record Pink <br />