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SAN JOAQUIN COTENTY E.45 OL ilLENT.,kL HEALTH DIVISIIo �,,! �L-kSTERFME RECO OR:VLATION FORVI(EH 00 69) - XJ ;Yew EH Program at Existing Facility ❑New EH Prouam and New Facility Facility ID IPA DO I 041D Program Record ID 1(1051& l 96 p7*_c 4 Facility Address I_Q_I_S S. Gi✓fo T-L TUaotF:r"ET -�t� T n (Please Check the appropriate description and specify size number of units and pertinent information.) J1��' �n e,.r FOOD PROGRAM(1600) 7'� ❑ Restauraot: Searing Capacity Square Footage Food Handlers Course reouired: YEs ❑ NO ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration I" License T Sticker R ❑ Mobile Food Prep Unit-Make Vehicle Type— Color— Registration ypeColorRegistration: License R Sticker n ❑ Temporary Food Facility--Dates ofoperation from to Cl Ice Plant ❑ Special Event - Dares of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Nfulti-Head Quit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGR.ANI(2200) ❑ Hazardous Waste Generator----------------Tots Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) �,/ ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste Ja ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST l UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hocel/Motel----Number of Units ❑ Jailor Exempt Institution—Number of Units Employee Housing(2700) Use Emo(ovee Housine/Lahor Camp loolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site Cl UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Fools/Spas at Facility Cl Pool Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number ofbirds ❑ Kennel TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registradon# License Capacity Vehicle m ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles-Number of Unirs ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10—❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRA31 ELEb1E,,r a3go FEE ❑Surcharge FEE ❑ Other FEE Lys PECTOR 2 PERMIT VALID to _ ❑ Food Handler. ❑ Check, A-NfouN-r PAID e INVOICE."r ❑ cssn R=vtExveD ayq1111Aceo rvTme OFF[eE Date y UD EH M69 Pr\K FOR-M.dcc Rev.07!07199