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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />VkNew EH Pro ram at Existing Facilit ❑New EH Program and New Facil(t <br />Facilit ID D�� Program Record ID �-P/7c7-L 72J <br />Facility Address "I 5 O W . McfN�e — FpaR <br />(Please check the appropriate description and specify size, number of units a d pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage <br />Commissary X Dry storage only with Food Preparation <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Retail Market ----Square footage ❑ w/Meat Market only <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged GoOds Only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Color <br />Registration # License At <br />❑ Mobile Food Prep Unit— Make <br />Slicker # <br />Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from <br />Color <br />Sticker # <br />❑ Special Event ---Dates of operation from to <br />to 13 ice Plant ❑Produce Stand <br />❑CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />C A <br />1I' — <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST)(2800) NumberofASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use LISTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Hous/ng/Labor Camp 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 ❑ 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 Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />1:3Pumper Yard 13Package Treatment Plant ElChemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (nor units) ❑ Dumpsters> 20 cu yet (nor 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 ❑ 2 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC W <br />ATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br />CONTACT PERSON_ --), "[. )^ <br />PROGRAM ELEMENT kc FEE <br />INSPECTOR# Ltf\ a( `)PERMIT VAL <br />❑ Check# egflj AMOUNT PAID <br />❑ Cash REVIEWED BY <br />48-02.034 <br />1/23/13 <br />Day Ph _7_UC1 — <br />❑ Surcharge <br />_ to9 <br />Date <br />) 3 2-n2, 7 <br />❑ Other FEE <br />❑ Food Handier <br />INVOICE #T <br />Date 7 � � / <br />