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S 2 O0 �S- 3 3 =}-(7 <br />SAN JOAQUINCOUNTY <br />STERFILE RE ON <br />RD FORMAT ON FORM <br />R C, <br />MAV� T <br />� <br />16 New EH Program at Existing Facili ew H Promo `ram, a�0q-/1n�d New Facili M <br />AY p 9 <br />Facility ID ��� Program Record ID t .X-79- / SAc ✓OA,,, _ , ?0<% <br />Facility Address I2 00U "Z3P-13V1 K02a1Ul , cd1 VIYLOV, l'/t I ✓�7V "�rH pEP FNTUNT� <br />(Please check the appropriate description and specify size, number of units and pertinent information.) ARTME/Vr <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: Yes ❑ No ❑ <br />❑ p mmissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />Retell 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 ❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <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 />❑ 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 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 Housing/Labor 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-NPLISEP 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 Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art 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 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 (#of unfts) ❑ Dumpsters> 20 cu yd (#& 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 46-02.003 Blue Application Form <br />CONTACT PERSON # �hG'e�7 <br />PROGRAM ELEMENT b� �FEE Cod <br />INSPECTOR �n/SPERMIT VALIaD <br />❑ Check # AMOUNT PAI21 <br />❑ Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />Day PI <br />❑ SS, <br />_ 10 <br />Date <br />ACCOUNTING OFFICE <br />Night Ph ao�l �oa5as�t <br />❑ Other FEE _ <br />❑ Food Handier <br />INVOICE # <br />Date lb 2, <br />5-Dv3 <br />3m - CAW -P <br />