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NAN JUAQUIN UOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />EH Proaram and <br />Facility Address L 1— N G7Vw 4- X3 t <br />(Please Check the appropriate description and specify size- number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: <br />Seating Capacity <br />Square Footage <br />Food Handlers Course reauired: YES ❑ No ❑ <br />❑ Commissary <br />❑ Dry storage only <br />❑ with Food Preparation <br />❑ Vending Machines —Number of Units <br />❑ Retail Market <br />----Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit --Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility -----Dates of operation from <br />to <br />_ <br />❑ Special Event --Dates of operation from <br />to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Bead Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator ------------Tons Generated Per Year_C S S 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 Emplopee Housing/Labor Camy 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 ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas 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 COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units <br />SOLID WASTE PROGRAM (4400) <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 ----- 02-10 ------- ❑ 11 - 60 ------ El > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWSEHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />�Unrna r rnn Wil r7 Lay Pn Night Ph <br />PROGRAM ELEMENT 07-?,L,::7FEE 2 L ❑ Surcharge FF. ❑ Other FEE <br />INSPECTOR# PERMIT VALID t9 to l -01 ❑ Food Handler <br />❑ Check # AMOUNT PAID Dated INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE /CX Date ,15 1,q/o S(-� <br />48-02-034 Masterfile Record Pink <br />11/18/03 <br />