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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Facility Address I,o I � • lU'rVl :. r� I r rt. is <br />(Please check the appropdate description and speciy size, number o} unlb <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑Dry storage only ❑with Food Preparation <br />❑ Retell Market—Square footage ❑ w/Meal Market only <br />r:>;v <br />� � � <br />.. <br />�-i � u^ <br />Food Handlers Course eL aulred: Yes ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ 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 # Slicker # <br />❑ Temporary Food Facility --Dates of operation from to ❑Ica Plant ❑Produce Stand <br />❑ Speclai Event—Dates of operation from to ❑CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dalry ❑ Grade B Dairy ❑ Mllk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑Program 1 Facllity ❑Program 2 Facllity ❑Program 3 Facllity <br />❑ Hazardous Waste Generator (2200) ------>-Tons Generated Per Year <br />❑ Tlared Pennitting Facllity -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facllity (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 />❑ HotellMotel—Number of Units ❑ Jall or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Emalovee Houslnc/Labor Camo Aoollcation Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Slte ❑Local HW Cioanup Slte ❑ NPLISEP Cleanup Site ❑ UIC Slte <br />❑ Abandoned HW Site ❑non-NPLISEP Cleanup Slte ❑ RWOCB Cleanup Site ❑Water Ouallty Remadlation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑Pool ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area <br />��cr•TOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ---Maximum number of birds ❑Kennel <br />TATTOO BODY IERCING PERMANEN COSMETIC ROGRAM (4100) <br />Body Art Practitioner Reg (4110) ❑ Mechanical DSPS NotlOcatlon (4115) ❑Body Art FacllltySingle Use (4120) <br />❑ Body Art FacllitySterlllzatlon (4121) ❑Body Art Temp Event Co-ord (4130) ❑Body Art -Temp Event Moblls Facllity (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehlDleRegistration# License# Capacity Vehicle# <br />❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑Transfer Station ❑ AglCannery Wastc Sita ❑Sludge/Ash Site <br />❑ Waste Tlra Facility ❑Compost Facllity ❑ ProcesslRecycle Facllity ❑ CIA Landfill Slte <br />❑ Refuse Vehicles (q of units) ❑ Dumpsters > 20 cu yd (q or units) ❑ FarmlRanch Cleanup Slte <br />�!pnICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Cllnlc ❑Common Storage Facllity ❑ 2 -10 ❑ 11 - 80 ❑ > 60 generators <br />P41-pl Ir t_"/ATER SYSTEM PROGRAM (4600) Use PWS EHD 46 02 003 Blua AnDI/teflon FOmt <br />EMERG NCY NOTIF ATION FOR HIS CILI ND/0 OGRAM <br />CONTACT PERSON Day P � � � Night Ph <br />PROGRAM ELEMENTJ110 FEE � ❑Surchar eF E ❑Other FEE <br />INSPECTOR# 9R:�L PERMIT VALID % y2 t0 � ❑ FOOd Handlef <br />❑Check # �SCL AMOUNT PAID . � ti Date � �- INVOICE # <br />❑Cash REVIEWED BY ACCOUNTING OFFICE Date 7� � <br />MASTERFILE RECO D INFORMATION PINK <br />46.D2.U34 l.X� � !�-G�1 `�73Z <br />rnana <br />