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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,,X&]l:I:t;9IN4:1x01•]:141ZITel:tItir_trLOIN ❑ New EH Program at Existing Facilit UNew EH Program and New Facility Facility ID Program Record ID % % Facility Address T6 I Gl A U P CJD�zMn �7� (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type Registration # License #_ ❑ Temporary Food Facility —Dates of operation from ❑ Special Event ---Dates of operation from to _ DAIRY PROGRAM (2000) Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand ❑CFO DAD ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) --- — ----- >-Tons Generated Per Year ❑ Tiered Permitting Facility------> OCA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel--Number of Units ❑ Jailor Exempt Institution —Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/ Site ❑ Waste Tire Facility 11 Compost Facility ❑ Process/Recycle Facility ❑ CIA/ 7"t ❑Refuse Vehicles (# or Units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/ o MEDICAL WASTE PROGRAM (4500) pt. 11 Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator ❑ Small Generator LTJ¢ r*H uler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 6Q$gH�> 60 gUenaws PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �ftwpb,,,Y,N C t". _ CONTACT PERSON Day Ph LO'j-yT-Z /Uy/Night Ph PROGRAM EL/F, )M FEE ❑ Surch r e FEE rr��r �� y, ❑ Other FEE INSPECTOR # IV_ PERMIT VALID 2Z t0 2.112.3 ❑ Food Handle ❑ �heeck`#' 1^ AMOUNT PAID Date �7 r 91(21,2-2j INVOICE#4 � gT46 v I�ty REVIEWEDEIYt�tJtAAA1 ACCOUNTING OFFICE r/1j//�t �Qi/Date �p�/ L �% 21i