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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />IY�77� Il <br />EH Proaram at <br />Facility Address <br />ase ch eck appropriate description and specify slime number units an pertinent <br />i-lr-vsc <br />_cgp*�rowN <br />0tL <br />StrF32 Sa«yccot_.) <br />CL <br />asp <br />(Ple the <br />d <br />' f ration <br />) <br />REcF �At T <br />0 D <br />In o <br />FOOD PROGRAM (1600) S4 A/ JO 2012 <br />❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course re b/R�Y�[,lcNo ❑ <br />❑ Commissary ❑ Dry storage only 13 with Food Preparation ❑Vending Machines Number 0 lei NF VNTY <br />13 Retail Market—Square footage E]w/Meat Market only 11 Multiple Departments EIPrepackaged !f's+ p� <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 --Dates of operation from to ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy <br />❑ 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 ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) 5, -Tons Generated Per Year. <br />❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel—Number of Units ❑ Jail or Exempt institution ---Number of Units <br />Employee Housing (2700) Use Emolovee Housing2abor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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 Far ----Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM <br />(4100) <br />tweff�Bodyr Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4 115) Body Art FacilitySingle 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 #. License # 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 (# or units) ❑ Dumpsters > 20 cu yd I# of units) ❑ Farm/Ranch 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 112 -10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 4642403 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON CHrttST\Ata F4SiLc�A jo Day Phjfu ,L6. 33gy Night Ph <br />PROGRAM ELEMENT1 U FEE 23'3 ❑ Surcharge FE El Other FEE <br />INSPECTOR # 3 PERMIT VALID WZ t0 � 36/,;2 =-� 11FOOd H ,. <br />❑ Check# AMOUNT PAID 11 00 Date 6 (ZZ_ INVOICE <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />49-02. 34 IJIASTER[ILE. <br />1/23119 17" X`/'&,- <br />