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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />❑ New EH Program at Existing Facility )(Jew EH Program and New Facility <br />Facility ID 0 Ul /'1 Z, rrogram tcccoru w [v <br />Facility Address 12.1 V11 E(m Lnr1 i <br />(Please Check the appropriate description and specify size- number of units and Ltinent information.) <br />QP��\NEo <br />Q�ONMFN <br />aNJ\PD <br />rFr�OOOD PROGRAM (1600) - <br />x>,Rcstaurant Seating Capacity 30 Square Footage Food Handlers Course required: Yrs ❑ 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 <br />Registration N <br />❑ Mobile Food Prep Unit --Make <br />Registration It <br />❑ Temporary Food Facility -----Dates of operation <br />❑ Special Event - Dates of operation - from_ <br />Vehicle Type <br />License 0 <br />Vehicle Type <br />License P <br />to <br />_ Color <br />Slicker 11 <br />_ Color <br />Sticker 0 <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) - <br />❑ Hazardous Waste Generator -----------------------Tons Generated Per Year <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 (ASI) (2390) ----Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and R forms <br />HOUSING PROGRAM (2400) <br />❑ IloteVMotcl------- Number of Units ❑ Jail or Exempt Institution—Number of Units <br />Employee dousing (2700) Use F.emlovec flousinr/Labor Ceram Annlicnrion Foran <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessuient ❑ 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 Arca <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farre --Maximum number of birds ❑ Kenucl <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vchicle--Registration S License N Capacity Vehicle N <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 Cl Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- 02 -lo ------- ❑ 11 -6o ------❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Fora <br />CONTACT PERSON Day Ph A'A—&�'�I'e' 100 <br />PROGRAM ELEMENT WZJ FEE 220 ❑ Surcharge FEE ❑ Other FRE. <br />INSPECTOR#���`� PERMITVALID t -i (4 - to I Z13( ft Z❑1 (Fg�000d Handler <br />ChcckN �:=-i AMOUNTPAID N lrl-ri �- Date A'aYf6��2 �4I 010E# /�/%toy <br />Cash REViEWEDBY Z.Z.4 L ACCOUNTING OFFICE <br />EH 11:69 PINK FORM.doc <br />Date I a. I 1 l 1 19-2T <br />Rev. 07/07/99 <br />