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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTR DEPARTMENT <br />❑ New EH Program at <br />Facili ID F' /(o /o L Program Record ID — " <br />Facility Address `� i e <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />OOD PR (1600) <br />estaurant: Seating Capacity Square Footage Food Handlers Course required: YECA No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending MachinesNumber of Units <br />❑ Retail Market—Square footage ❑ w/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 Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility -Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event—Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ----->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USIA and 9forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (223 1) ❑ PBR HHVV (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution ---Number of Units <br />Employee Housing (2700) Use Employee Houskw/LaborCamp AupBcation Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local 14W Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP 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 ❑ Kennel <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <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/A I <br />❑ Waste Tire Facility ❑Compos[ Facility ❑ Process/Recycle Facility ❑CIA Lank Ivr <br />❑ Refuse Vehicles to of unim) ❑ Dumpsters > 20 cu yd (# of unite) ❑ Farm/Rapcph�Cle s <br />MEDICAL WASTE PROGRAM (4500) JUiy ?? w <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small General o$.4g1 ited Halo' <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60y(g)y�rators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-01-003 Blue Application Form wry p NMEVOONry <br />EM RGENCY NO FICATION FOR THIS FACILITY AND/OR PROGRAM Ep'rMENr <br />CONTACT PERSON Markt (,J i1 rI I Day Ph •�'i��' 3 3 Night Ph�li1.i'ViP <br />PROGRAM ELEMENT 1114e /" 7 FEE ZV V VW ❑ Surchar e F E 11 Other FEE <br />INSPECTOR # PERMIT VALID t0 ❑ Food Handler <br />Check # [�AMOUNT PAID Date /� � It) Z INVOICE # <br />11 Cash REVIEWED BY1 11 M ACCOUNTING OFFICE td J)77;� /jl Date 61-712-l' <br />1!23113 <br />