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SAN JOAQUIN C;OUNI Y FNVIKONIVIEN IAL HLALTH UEI'ARI NIEN1 Facility ID FH C Facility Address Record ID (Please Check the appropriate description and specify size• number of units and Pertinent information.) FOOD PROGRAM (1600) ❑ 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 # ❑ Temporary Food Facility ----- Dates of operation from ❑ Special Event --Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dalry ❑ Grade B Dairy Vehicle Type License # Vehicle Type License # Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines —Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only _ Color Slicker # _ Color Sticker # to ❑ Ice Plant ❑ Produce Stand ❑ Milk Dispenser ---Number orConlainers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑Recle / Exem t System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) �4ppliance Recyclers (2217 Tiered Permitting Facility — ❑ Conditionally Authorized (CA) Conditionally Exempt ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B !arms HOUSING PROGRAM (2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution --Number of Units Employee Housing (2700) Use Employee Housina'Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment - ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned tIW Site ❑ non-NPI./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 (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) 11 Pumper Vehicle --Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of 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 --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 ------ 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-02-003 Bltte Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Dav Ph Night Ph PROGRAM ELEMENT 7,7,(-7 FEE _ INSPECTOR# 41.6 PERMITVALID ❑ Check # AMOUNT PAID ❑ Cash REVIEWED BY ❑ Surcharge FEE ❑ Other FEE _ _ to ❑ Food Handler Date INVOICE # ACCOUNTING OFFICE. Dale 48-02-034 Masterfile Record Pink 11/18/03