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SAN JOAQC- IN COUNTY EN VIRONNIENTAL HEALTH DEPAR, NIA-,TRRFILE RECORD INFORlIATION FOI 'll ;ENT []New EH Program and New Facil ew EH Pro�am at Existin Facility _ O Gl l/� Program Record ED 3 �Lf(12 Facility ID �i� , , Facility Address �� ` (Please Check the appropriate description and specify size, number r of units and pertinent information.) FOOD PROGRAM (1600) Food Handlers Course required: - YEs ❑ No ❑ _ ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary C1 Dry storage only C1with Food Preparation ❑ Vending i\Iachines --Number of Units ❑ with Meat Market only [I Multiple Departments ❑Prepackaged Goods Only ❑ Retail Market ----Square footage Vehicle Type ❑ Mobile Food Vehicle -----Make License Registration # Vehicle Type ❑ Mobile Food Prep Unit --Make License # Registration # to ❑ Temporary Food Facility -----Dates of operation from ❑ to Special Event --Dates of operation from _ Color Sticker #— _ Color Sticker #_ ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ 'Milk Dispenser --- Number of Containers in Multi -Head Unit ❑ Grade A Dairy ❑ Grade B Dairy COPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) Tons Generated Per Year ❑ Recycle / Exempt System (2299) ❑ Hazardous Waste Generator ------------T Silver Only (2232) ❑ Appliance Recyclers (2217) ❑ CRT Offsite Handlers (2218) - ❑Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) Tiered Permitting Facility------------' Rule Household Hazardous Waste ❑ Permit -By -Rule Fixed Unit ❑ hermit -By- (BOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST L rDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) 11 Jail or Exempt Institution ---Number of Units ❑Hotel/i`Iotel-------Number of Units Employee Housing (2700) Use Employee Honsin�/Labor Camp Application Fornt SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000)ite UIC Site ❑ Environmental Assessment ❑UST -CAP Site ❑ Local HNaCleanup B Cleanup Site it NPL/SEP Cleanup S Water Quality Remediation Site ❑ Abandoned HW Site ❑non -N L/SEP Cleanup Site RECREATIONAL HEALTH PROGRAM (360ElNatural Bathing Area Number ofPools/Spas at Facility Clool CO3 Spa out of Service pool/Spa VECTOR CONTROL PROGRAM (4000) ❑ Kennel ❑ Poultry Farm -----Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC ooPR g(4120 (4100) ❑ Tattooing (4121) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration #— ❑ Pumper Yard ❑ Permanent Cosmetics (4122) VohirlP �. _ License # t-apacny ❑ Chemical Toilets -------Number of Units ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles --Number of Units MEDICAL WASTE PROGRAM (4500) ❑ Small Generator 13 Limited Hauler ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator 0I 1 - 60 -----❑ > 60 generators El Primary Care [I Common Storage Facility ----- 2 - 10 ------- ❑ Transfer Station ❑ Veterinary Clinic PUBLIC WATER SYSTEM PROGRAM (4600) Use P«'S EHD 4FOR T03 Blue ILI-T' Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM ight h Day Ph e-nv.rrArT PERSON 11 Sludge/Ash Site ElAg /Cannery Waste Site [I CIA Landfill Site ❑ Process/Recycle Facility ❑ Farm/Ranch Cleanup Site ElDumpsters> 20 cu yd ----Number of Units PROGRAyI ELEMENT D FEE _ INSPECTOR # 13—r-1 - PERMIT VALID ❑ Check # AMOUNT PAID— Dr "—wrn RV U %-asp 48-02-034 ❑ Surcharge FEE __ ❑ Other FEE ❑ Food Handler to Date ACCOUNTING OFFICE INVOICE # Date— Masterfile Record pink