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•SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />M <br />❑ New EH Prooram at <br />ATION <br />I��ZL�1.7►�/SiliS: .. , rr : - � !_�.ii•Si�L!�I <br />Facility Address 1�50 S- raliBroij2' s- StLklyrl 9gi6 <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 required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />0J2etail Market --Square footage ❑ w/Meal Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />10 Mobile Food Vehicle --Make Vehicle Type Color <br />/ Registration # License # Sticker # <br />N Mobile Food Prep Unit— Make Ch f V Vehicle Type Color <br />Registration # I(, wip i ( TI 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 ❑ 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) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A 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 Housing/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-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_ <br />❑ 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 />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) l�q <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludl <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Land i l4/ <br />❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Far**r f leanup Site <br />MEDICAL WASTE PROGRAM (4500) AAN 99 2022 <br />1:1 Primary Care ❑ Acute Care 1:1 Skilled Nursing 1:1 Large Generator 11 Small Gen - tV,6 /ayu�yler <br />❑ Transfer Station 11Veterinary Clinic 11 Common Storage Facility 112 -10 1111 = �AL T810rs <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON,,,le �eOr6a✓1 i P L I lC( Day Ph SCI %`l Night Ph <br />PROGRAM EALEAMIENT FEE Vv ❑ Surch/arge FEE 11 Other FEE <br />INSPECTOR# �F'i- PERMITVALID I �-f-� t0 I 1/ ❑ Food Handler <br />❑./Check # AMOUNT PAID 2 Date Z '112� INVOICE # <br />Liz Cash REVIEWED BY1.000' ACCOUNTING OFFICE Date 2_ <br />4"2-034 MASTERFILE R CORD INFORMATION PINK <br />1123/13 <br />