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SAN JOAQUIN COUNTY <br />❑ New EH <br />Facilitv ID <br />y �l '7 <br />Facility Address <br />VIRONMENTAL HEALTH DEPAF ENT <br />TION <br />m <br />r <br />New <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 reguired- 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 <br />Registration # Color <br />❑ Mobile Food Prep Unit License # Sticker #_ <br />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 />❑ Grade A Dairy ❑ Grade B Dairy <br />COPA ❑State Facility Surcharge (2399) ers n ultl-Head Unit <br />HAZARDOUS WASTE PROGRAM (2200) <br />iazardous Waste Generator----------- Tons Generated Per Year Z� ElRecycle/Exempt System (2299) <br />ElCRT Offsite Handlers (2218) ------------ ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility------------------- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />13Permit-By-RuleFixed Unit 11Permit-By-RuleHousehold Hazardous Waste <br />1:1ABOVEGROUND 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 />ElHotel/Motel ------ Number of Units ElJail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />ElEnvironmental Assessment ❑ UST -CAP Site 1:1Local HW Cleanup Site ElNPL/SEP Cleanup Site ElUIC Site <br />ElAbandoned HW Site ❑ non-NPUSEP Cleanup Site ElRWQCB Cleanup Site ElWater Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 13Pool ElSpa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />ElPoultry Farm -------Maximum number of birds ❑ Kennel <br />Eli <br />Milk Dispenser -Number of Contain M <br />Color <br />_ ElIce Plant <br />❑ Produce Stand <br />TATTOO, BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) 11Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />ElPumper Vehicle Registration # <br />ElPumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <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 ❑ 2 - 10 ❑ 11 - 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 />CONTACT PERSON Day Ph _ Night Ph <br />PROGRAM ELEMENT FEE_ <br />INSPECTOR # Y15 PERMIT VALID <br />❑ Check # AMOUNT PAID _ <br />12 Cash REVIEWED BY <br />❑ Surcharge FEE ❑ Other <br />to <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE # <br />Date <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />11/15/07 <br />