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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />111 41010 11-.,% i [s7 7 701 :7 11 <br />❑ New EH Proaram at Existinq Facilitv ®New EH Program and New Facility <br />Record ID <br />Facility Address `1 77)_ —,_-)cMol Z::>T '--P -E-)/-L1 U <br />(Please check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity CNF. Square Footage 160 Food Handlers Course required: YES M No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending Machines Number of Units oNE, <br />Ed Retail Market ---Square footage .6 0 11w/Meat Market only IJMultiple 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 ❑ <br />❑ Special Event --Dates of operation from to ❑ CFO ❑ A ❑ B <br />Produce Stand <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 Housina/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation 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 ❑ 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 Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # License At Capacity 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 ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (a of units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/R4%?,Vnup Site <br />MEDICAL WASTE PROGRAM (4500) �/+T��.��''l/EN% <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑f I�r iflC�,l�t, <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 Rf#0 enerat-09 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �1 U 2023 <br />I c........,..v u,.���....r.,..�.....r�� CA ru 1rv..,,.t..e oonco A KA <br />SAN Jn.,.. <br />CONTACT <br />PROGRAM <br />FEE <br />INSPECTOR#II n� PERMITVALID <br />V4El AMOUNT PAID <br />h VjhJ4 REVIEWED SY <br />4/23/13 <br />1/23/13 <br />Il'.. riV7 <br />JLQ T Day Ph <br />❑ Sui <br />Z t0 _ <br />Date <br />ACCOUNTING OFFICE <br />Night Ph HEet',:rKt <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE# 3 <br />Date 317/2 <br />