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ENVIRONMENTAL HEALTH <br />SAN JOAQUINMAST RF LE RECORD INFORMATION FORMDEPARTMENT RFAC� FcNT <br />New EH P ram at Ezlsfln Facility- ❑New EH Proram and New Facili <br />FacilityID o Program Record ID 5 � q17 <br />SAN,,C) <br />ty <br />TPlReaseicheckaeeappropriate des �ptiol�nd specify sib number units and Pertinent Information.) HEA TN p NMEN UNry <br />FOOD PROGRAM (1600) EPART/yENT <br />W Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YEs ❑ No ❑ <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—Dates of operation from to !19�C_FO SOA ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dalry ❑ Milk Dispenser -Number of Containers in Multi -Head Unit _ <br />CUPA <br />ff Hazardous Materials Business Pian (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) ❑PBR (2231) ❑ PBR HHW (2236) <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 />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel —Number of Units ❑ Jail or Exempt institution —Number of Units <br />Employee Housing (2700) Use Employee Hous/nati. or 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-NPL/SEP 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 AR Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body AR Facility -Single Use (4120) <br />❑ Body AR Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # License # Capacity Vehicle #- <br />• Pumper <br />❑Pumper Yard ❑ Package Treatment Plant ❑ChemicalToilets—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 is of units) ❑ Dumpsters> 20 cu yd (#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 ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02.003 Blue Application Form <br />PROGRAM ELEMENT U FEE ❑ Suroh a FE ❑ Other FEE <br />INSPECTOR #�p�� ��y PERMIT VAD O �- ZD tto <br />D ❑ Food Handle <br />❑ Check# S:LCSSJ7_ AMOUNT PAID Date � INVOICE# <br />❑ Cash REVIEWED eY ACCOUNTING OFFICE i Date 7 7 W <br />Scanned with CamScanner <br />