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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />11\14ew EH Program at Existing Facility ❑New EH Program and New Facilitv <br />Facility Address 1 1 1 1 S, A-C�oNA-,AT s� <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 Course required: 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 Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit Make Vehicle Type _ <br />Registration # License # Sticker # _ <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />H ARDOUS WASTE PROGRAM (2200) ff <br />'Hazardous Waste Generator --------Tons Generated Per Year C J ❑ Recycle/Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ---------❑ Silver Only (2222) ❑ Appliance Recyclers (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 <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 Housina/Labor 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds <br />TATTOO. BODY PIERCING. PERMANENT COSMETIC PROGRAM (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 />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles 0 of units) <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets --Number of Units <br />❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ranch Cleanup Site <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 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />PROGRAM ELEMENT <br />ar „ <br />ri i <br />FEE 213. O U ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# 516`47� PERMIT VALID <br />❑ Check # AMOUNT PAID Date <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE #�� <br />Date/ v//� <br />Yckp6ol'­ 13l LL— IsEf� 1N Nl NLSZ-Oc 1 <br />48-02-034 "' 1 (/�JMASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />