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COUNTY ENVIRONMENTAL HEALTH <br />nFaellAYMENTEI New EH Program at Exls <br />Facility ID%' '. i�' (�� Program Record ID 7l / c' G.;,�i� a RECEIVED <br />Facility Address 15� �tsy11� 1 �qL. �k_.f>r�q_�'. , GPt �15�jjo MAR i 202 <br />(Please check the appropriate description and specify size, number of units and pertinent Information.) SAN jOA <br />FOOD PROGRAM (1600) HEAL IRONM�CyONNTY <br />❑ Restaurant: Sealing Capacity. Square FootageFood Handlers Course reaulrel 05esn ❑ <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 # 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 ---Dales of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number Of Containers in Multrilead Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals, <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year. <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235. 2237) ❑ <br />PBR <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />El Other CUPA Program <br />(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) riNDERGROUND INJECTION CONTROL (3000) <br />El Environmental Assessment ❑ UST -CAP (� Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />El Abandoned HW Site ❑ non -NPL; ,ul; Site ❑ RWQCB Cleanup Site ❑ Water Quality Remedlation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of POOIS/Spas at Facility „ ❑ Pc: >' p El Out of Service PooilSpa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) ❑ Kennel <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) (1 Mechanical DSPS Notification (4115) C3 Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration <br /># License fl Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant [I Chemical Toilets ----Number of Units. <br />SOLID WASTE PROGRAM (4400) <br />El Landfill LJ Transfer Station C1AglCannery <br />Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessiRecycle Facility ❑CIA Landfill Site <br />❑ Refuse Vehicles (a a units)tA) <br />❑ Dumpsters > 20 cu yd (a of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care C1 Skilled Nursing 11 Large Generator [3 Small Generator C1 Limited Hauler <br />[I Transfer Station EI Veterinary Clinic El common Storage Facility ❑ 2 - 10 (3 11-60 ❑ > 60 generators <br />>UBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form <br />_ r„o Tues FACILITY ANDIOR PROGRA_� <br />"ONTACTPERSON l t1vT\�I r1,t•rr <br />pROGRAM ELEMENT Nlla FEE � <br />NSPECTOR# PERMIT VALID, <br />� (i-- Check # ,>AMDDnN T PAID <br />oml]ClAlrn RV ` b*" -4t 1�� <br />Day Ph <br />❑ Surchal <br />3 to <br />Date <br />y31 ACCOUNTING OFFICE <br />O Other FEE <br />❑ Food Handler <br />INVOICE# <br />Date .3/1 q/2-1 <br />