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■.— <br />SAN JOAQUIN C <br />:HEALTH <br />N� ew EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility Address \AQ `.atC1�Ue <br />(Please Check the appropriate description and specify size• number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing CapacitySquare Footage <br />Food Handlers Course required: Yrs El No C1 <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Market •---Sfootage ❑ with Meat Market only ❑ Multiple Departments [3 Prepackaged Goods Only <br />Retail quaze <br />Color Type ype <br />Cl Mobile Food Vehicle --Make Vehicle$ticker # - <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operation from <br />Vehicle Type <br />License # <br />Color <br />Sticker # <br />LJ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeuser—Number of Containers in Multi -Head Unit <br />CUPA ❑ S e Facility Surcharge (2399) c <br />HAZA OUS WASTE PROGRAM (2200) Tons Generated Per Year <br />Hazardous Waste Generator --------------------- <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ HoteUivlotel-------Number of Units 11 Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Emnlavee Ho cit ^/L bo Camn Anolicadon Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment Cl UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />Number of PooWSpas at Facility ❑ Pool ❑ Spa <br />VECTOR CONTROL PROGRAM (4000) Cl Kennel <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) C3 Permanent Cosmetics (4122) <br />❑ Tattooing (412 1) <br />C1 Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) CapacityVehicle # <br /># License # <br />❑ Pumper Vehicle—Keg stratton <br />❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />❑ Pumper Yard _ <br />SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash Site <br />❑ Landfill ❑ Transfer Station ❑ Ag l Cannery Waste Site <br />❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small ❑Generator -0 11 >t60 generators <br />r <br />❑ Transfer Station ❑ Veterinary Clinic [I common Storage Facility —❑ 2 - IO — <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS E90069 Blue Annlicadoa Form <br />TY IOR PROGRAM <br />EMERGENCY NOTIFICATION FOR THIS FACILI AND <br />Day Ph Night Ph <br />CONTACT PERSON <br />❑ Surcharge FEE [3 Other FEE <br />PROGRAM ELEMENT ZQQ FEE _�-- / _V [I Food Handler <br />L(+ <br />p-� PERMIT VALID /"� t0 — <br />INSPECTOR# �f INVOICE# i%fJ ? <br />Check#AMOUNT PAID �— Date <br />❑ <br />❑ Cash REVIEWED BY ACCOUNONG OFFICE 7J <br />Re 07/07i99 <br />