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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT _ ){I New EH Program at Existing Facility ❑New EH Proqram and New Facility Facility IU I 1 7 W L. Program Record ID -) KL? 530 )6 Facility Address 1-5 6`6`6 e- •9n)) y S I'D (Please check the appropriate description and specify size, number of units and pertinent Information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity _ Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration If License # Sticker # ❑ Mobile Food Prep Unit Registration # ❑ Temporary Food Facility –Dates of operation from ❑ Special Event Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Make License # to to Vehicle Type — Sticker # Color _ ❑ Ice Plant ❑ Produce Stand ❑ 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 ❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution --Number of Units Employee Housing (2700) Use Employee HousinpyLabor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 Podl/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) ❑ 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 (# of units) ❑ Dumpsters > 20 cu yd (# 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 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue ADplicatlon Fenn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM • uay rn Night Ph PROGRAM ELEMENT 2220 FEE 2 13 • 00 ❑ Surch0 FEE ❑ Other FEE INSPECTOR# /,(n�D PERMIT VALID Dt Ot 10 to 12-7111p ❑FOOd Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date O, /-6cL 2.. • IL 6L... w1. -1 f- 48-02-034 - ae-a2-0MASTERFILE RECORD INFORMATION PINK 11I15I07 /`tr„rte{ /1