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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />❑ New EH Program at <br />ID <br />INFORMATION FORM <br />Record ID <br />PAY41 <br />Facility Address RCCECEIVED <br />c an <br />check escnp ton <br />(Please ec appropriate specify size, number of units and pertinent information.) <br />c7`7d-J& <br />M <br />w* <br />11° rlvkxW <br />La�- <br />Art Practitioner Reg (4 110) ❑Mechanical DSPS Notification (4115) <br />UP it <br />F <br />❑ Body <br />Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />❑ Body <br />Art -Temp Event Mobile Facility (4131) <br />Dumpsters> 20 cu yd (#of Units) <br />❑ Farm/Ranch Cleanup Site <br />PI thet <br />description <br />d <br />❑ <br />Primary Care ❑ Acute Care ❑ Skilled <br />Nursing <br />SC� <br />09 2072' <br />FOOD PROGRAM (1600) SIV JO QQryUII/ COl�y <br />Elre <br />Restaurant: Seating Capacity. Square Footage Food Handlers Course guirEWALTq FI 737 <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units �TMENT <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 Vehicl0T ype Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant <br />Produce <br />11Special Event ---Dates of operation from to ❑ CFO 11A ElB <br />DAIRY PROGRAM (2000) <br />Stand <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 />❑ CalARP 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) ❑ PER. (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 Employee HousinglLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -•"----Maximum number of birds <br />TATTOO, BODY PIERCING, <br />❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br />❑ Kennel <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration <br />El Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />11 <br />PERMANENT COSMETIC PROGRAM (4100) <br />El <br />Ag/Cannery Waste Site <br />11 Sludge/Ash Site <br />❑ Body <br />Art Practitioner Reg (4 110) ❑Mechanical DSPS Notification (4115) <br />❑Body <br />Art Facility -Single Use (4120) <br />❑ Body <br />Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />❑ Body <br />Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration <br />El Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets ----Number of Units <br />11 <br />Landfill El Trans Station <br />El <br />Ag/Cannery Waste Site <br />11 Sludge/Ash Site <br />❑ <br />Waste Tire Facility ❑Compost Facility <br />❑Process/Recycle <br />Facility <br />❑CIA Landfill Site <br />❑ <br />Refuse Vehicles (#of units) <br />❑ <br />Dumpsters> 20 cu yd (#of Units) <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ <br />Primary Care ❑ Acute Care ❑ Skilled <br />Nursing <br />❑ Large Generator ❑ <br />Small Generator ❑ Limited Hauler <br />❑ <br />Transfer Station ❑ Veterinary Clinic <br />❑ Common <br />Storage Facility ❑ 2 -110 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC <br />WATER SYSTEM PROGRAM (4600) Use PWS <br />EHD 46.02-003 Blue Application Form <br />CONTACT PERSON UY) U /,LG1 <br />PROGRAM ELEMENT FEE <br />INSPECTOR# PERMIT VAL <br />❑ Check # 2 I AMOrUNT PAID; <br />❑ Cash REVIEWED BY 1 ,fl A ✓_f <br />48-02-034 <br />1/23/73 <br />Ull ❑Surer e FE <br />to <br />.OD Date q s' <br />ACCOUNTING OFFICE <br />O(�3zzT <br />Kph Cf��o'7f� <br />❑ Other FEE <br />❑ Food Handler <br />ICE#4a, <br />Date q A -) <br />PINK <br />