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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 114►_61d�:7g1�� EH Program at ❑New EH Program and New Record ID Facility Address ";no r� AnU L1� s�ct�TOAJ Gr) (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 recuired: 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 --Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit-- Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ 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 -------> ❑ CA (2232) ❑ CE (22333 2234, 2235, 2237) ❑ 13Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use E_mplovee Housino/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ TATTOO. BODY PIERCING, ❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel LIQUID WASTE PROGRAM (4200) ❑ Pumper VehicleRegistration# License # Capacity Vehicle # 1:1 Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets ----Number of Units_ SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (u or units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ For/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) I� 11.. ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Genera 7.� uler ❑ Transfer Station ❑ Veterinary Clinic ❑Common Storage Facility ❑ 2 - 1D ❑ 11 - 6Qp„�� /�AWeiators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form E E GENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM _--vY�_ CONTACT PERSON (-Q2 Day Ph -7 - tjZNi Rip PROGRAM ELEMENT HIIO FEE fift ❑ Surch /raeF E ❑ Othe v IN,S/P,ECTO gtS3 PERMIT VALID to �/ 3Z7 ❑ Food Hand DO C� %:MOUNT PAID Date INVOICE # 3 S12 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ZL- 48-02-034 NIASTERFILE RECORD INFORMATION PINK 1/23113 PERMANENT COSMETIC PROGRAM (4100) pfd Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (41 15) ❑ Body Art Facility -Single Use (4 120) ❑ 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 # 1:1 Pumper Yard ❑ Package Treatment Plant ❑Chemical Toilets ----Number of Units_ SOLID WASTE PROGRAM (4400) ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (u or units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ For/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) I� 11.. ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Genera 7.� uler ❑ Transfer Station ❑ Veterinary Clinic ❑Common Storage Facility ❑ 2 - 1D ❑ 11 - 6Qp„�� /�AWeiators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form E E GENCY NOTIFICATION FOR THIs FACILITY AND/OR PROGRAM _--vY�_ CONTACT PERSON (-Q2 Day Ph -7 - tjZNi Rip PROGRAM ELEMENT HIIO FEE fift ❑ Surch /raeF E ❑ Othe v IN,S/P,ECTO gtS3 PERMIT VALID to �/ 3Z7 ❑ Food Hand DO C� %:MOUNT PAID Date INVOICE # 3 S12 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ZL- 48-02-034 NIASTERFILE RECORD INFORMATION PINK 1/23113