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SAN JOAQUIN COUNTY -r[RONMENTAL HEALTH DItii, <br /> VLASTERFILE RECO'T�LNIFORVL-kTION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilitv ID r....L t Program Record ID <br /> Facility Address 1F?b [t=,tkT M[Lr-- 'moi LGhi <br /> (Please Check the appropriate description and specify size- number of units and vertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Veading Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License T Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration g License A Sticker.+ <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dalry ❑ Grade B Dairy ❑ ititilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Cl Hazardous Waste Generator-----------------Tors Generated Per Year <br /> Tiered Permitting Facility ❑ Coadirionally Authorized(CA) ❑ Condirionally Exempt(CE) <br /> ❑ Pertrut-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> iYABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROn'D STORAGE TANK(UST) PROGRAM(2300) Use USIA and B!arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Horel/Motel-----`lumber of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee HousinglLahor Camp Aoylication 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 ❑ oon-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility C3 Poo( ❑ 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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle—Registration g License Capacity Vehicle R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Tnosfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number 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 <br /> ❑ Common Storage Facility —❑ 2- 10—❑ it -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Avolication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEXENTgZ61 o FEE ❑ Surcharge FEE ❑ Other FEE <br /> LY$PECTOR'# PFJLMrr VALID to ❑ Food Handler <br /> { ❑ Check p AMOUNT PAID . Date INVOICE T <br /> ❑Cash REV[EWrDBY ,3jjj16V ACCOtrrMGOFFICE Dace 4�(;-; •:_ <br /> p,,.07/07/99 <br /> EH C069 PrN-K FORMAcc <br />