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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />FORM <br />Io-doo <br />Facility Address 9 7-w f-011nllrrl /19 = ff Y /A <br />(Please check the appropriate description and specify ssM number of units <br />FOOD PROGRAM (1600) <br />❑ Rgstaurant: Seating Capacity Sgl�are Footage <br />Commissary Ury storage onty Kilth Food Preparation <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />j <br />PAYMENT <br />ogram and New Facilt <br />- <br />- .FEB 0 9 2022 <br />���,��,�- <br />"� .-1 <br />'AN <br />pertinent information.) <br />jOU <br />ININ CCU TY <br />NEE RO <br />ALTH DERT <br />Food Handlers Course required: YEs NoNT <br />❑Vending Machines Number of Units <br />❑ 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 />COPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) -->-Tans Generated PerYear <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 UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <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 ❑ NPUSEP Cleanup She ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQC13 Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) - <br />13 Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art FacilitySingle Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Cc-ord (4130) []Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicieRegistration # 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 ❑ SludgelAsh Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of 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 1:12 - 10 ❑ 11-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application FOnn <br />ERGENCY NO CATIV FORTHIS I-AGILI I T ANDIOR YKUUK ffl y� <br />CONTACT PERSON 1 �/ Day Ph %a' 7Iyv Night Ph PP"G��-? r <br />PROGRAM ELEMENT ([4!F <br />r FEE 41S4 ❑ Surrha o Fc ❑ Other FEE <br />INSPECTOR# L"nho. PERMITVALID 2-9- Z.2 to 1` O ElFood Handier <br />❑Check# AMOUNT PAID 2,37 �� Date 22- • INVOICE# <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />4892-034 MASTERFILE RECORIY INFORMATION PINK <br />1!23/13 <br />13�GF-8/%3 <br />