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JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />11 Facility ID T-Ah01=Z6L l Proaram Record ID -'ko,� 4477`ff `i 11 <br />Facility Address IGI I 3 ,V( O+V) jt M bif,1 <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 />❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # <br />❑ Mobile Food Prep Unit-- Make <br />Registration # <br />❑ Temporary Food Facility -Dates of operation from <br />❑ Special Event --Dates of operation from <br />License # Sticker # <br />Vehicle Type Color <br />License # l L 1�1 Sticker # <br />to ❑ Ice Plant ❑ Produce Stand <br />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 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 ❑ 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (itofunifs) <br />❑ Natural Bathing Area <br />❑ Ke W) <br />11 Body Art FacilitySinglerOggg4 VED <br />❑ Body Art -Temp Event MoMICT1091) <br />Capacity NW0QI nN COUNTY <br />❑ Chemical Toilets ---Number of UnitsIRENV ONMNNT <br />HEALTH oEpgn <br />❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd (4 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 112 - 10 ❑ 11 -60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />• - • �vSiC�tt5L';�9,� •- Vl�:li.1CTr'L`1:.� <br />PROGRAM ELENRNT I W -? J FEE J;�-Y-9 f VV ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # <br />❑ Check # A <br />❑ Cash REVIEWED BY <br />48-02-034 <br />123113 <br />PERMIT VAL <br />MOUNT PAID <br />-V o.Lo Jok to j' <br />L3� Date <br />ACCOUNTIVy NG OFFICE <br />❑ Food Handler <br />INVOICE# 5G-ri <br />Date <br />MASTERFILE <br />PINK <br />