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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL <br />EH <br />DEPARTMENT <br />Facility ID Program Record ID �$ <br />Facility Address E W <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course reouired: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ With Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market --Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Mobile Food Vehicle -Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Mobile Food Prep Unit- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker# <br />❑ Temporary Food Facility -Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ 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 />❑ 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) ❑ PBR (2231) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use LISTA 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 ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles I# of units) <br />❑ Body Art Facility -Single Use (4120) <br />❑ Body Art -Temp PAl�Mab Nrrcility (4131) <br />Capacity tAlVpE_ial/iil/i IIICC�fVVdw <br />❑ Chemical Toilets--Numbe�Vr )s <br />UU, 02, <br />❑ Ag/Cannery Waste Site SAIP&(K"/68�& <br />❑ Process/Recycle Facility Fi9�MBlgr[059LSite <br />❑ Dumpsters> 20 cu yd (# of units) HEt9T0a?E7�hWI3Teanup 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 EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSOpt S "Wjn Kj , Day Ph 7&,c ) 717-7Night Ph <br />PROGRAM ELEM NT EE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR PERMIT VALID t0 11 Food Handler <br />❑ Check # AMOU/NyT PAID n—Date y INVOICE # <br />❑Cash REVIEWED BY ( nIU-61 ACCOUNTING OFFICE / / Date E'1 <br />1/23113 <br />