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C SAN JOAQUIN COUNTY <br />RNENTAEADEPARTMENT V�^�E RECORD INFORMATION O <br />❑ Now EH Program at ExistingFacilityNow FH Pr tom and Now Facllll D` C ? 8 <br />Facllif ID Pro ram Record ID gIll-�(%`��� S fN OgQUIN 7422 <br />e Faci(pleaslity Addrechock ss Prin3 description and specify size,number of unite and r�or1 Information.) Hf ALT yOf pg" Tr/4 Y <br />FOOD PROGRAM (1600) <br />❑ Restaurant Sealing Capacity_ Squera Footago Food Handlers Course reauirod: yts ❑ No ❑ <br />❑ Cornmissary ❑ Dry storage only ❑ with Food Preparation []Vending Machlnostfumbor o(Untls <br />6d Retail Market—Square footage -7afM ❑ w/Meat Market only Bliultiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make Vehicle Type Color <br />Registration # License # Slicker # <br />❑ Mobile Food Prep Unit- Make Vehicle Tyle Color <br />Registration # License # Slicker # <br />❑ Temporary Food Facility -Dates of operation from to _ ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event—Oates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dalry ❑ 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 --s, OCA(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 />❑ HotellMotel —Number of Units ❑ Jail or Exempt InatRutlon ---Number of Units <br />Employee Housing (2700) Use Employee Housina/Labor Camp Application Form <br />SITE MITIGATION (2900) (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site 11 Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Silo ❑ RWQCB Cleanup Site ❑ Water Quality Remedlatlon 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 Tomp Event Co-ord (4130) []Body Art -Tamp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration n License n Capaaty _ 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 ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles Is or U,isi ❑ Dumpsters > 20 cu yd is at uNul ❑ Fam-dRanch 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 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />0 CONTACT PERSON 1`-- V Y GSk1 j h c nay all r Day Ph�-�i i jNlght Ph <br />PROGRAM ELEMENT i ( FEE �C) � ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # L \t\i\o f2S PERMIT VALID Z -Z9 Zi_ to ` - - 2 ❑ Food Handier <br />❑ Check a SG -r AMOUNT PAID �— Date 2 2-1- <br />3 <br />-Z INVOICE p <br />❑Cash REVIEWED BY ACCOUNTING OFFICE Date / Shy. <br />OW -4 /S47S5357 <br />