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J <br /> SAN JOAQUIN COUNTY <br /> 1RONNIErT:AL HEALTH DIVI�i <br /> LNLkSTERFILE RECO° NTORINLATIONL FORNI(EH 00 69) <br /> New EH Program at Existing,Facility ❑New EH Pro am and Yew Facility <br /> Facility IDProgram Record ID <br /> Facility Address I V11 "1 cwLGi 'Rd. , Lo_4�.rop <br /> (Please Check the appropriate description and specify size, numberof units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market--Square footage ❑ with,41eat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration M License P Sticker <br /> ❑ Mobile Food Prep Unit--stake Vehicle Type Color <br /> Registration T License# Sticker T <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 Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGR-ANI(2200) <br /> ❑ Hazardous Waste Generator ------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST 2 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2 700) Use Em to ee ffousinLahorCam rIv licalion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local H"Y Cleaaup Site ❑ NPLlSEP 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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration T License Capacity Vehicle"r <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—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rancb Cleanup Site <br /> MEDICAL WASTE PROGRAM(4300) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ SmaIl Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —132- IO ElI 1 -60—0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS FH0069 BlueAnalicatioR Form <br /> EMERGENCY NOTIFICATION FOR THOS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGPwl ELVAENT 0 03qD FEE ❑ Surcharge FEE ❑ Other FEE <br /> LNSPECTOL0 i PEFW1717 VALID to ❑ Food Handier <br /> ❑ Check# AIMOUNT PAID Date INVOICE rt <br /> ❑ Cash REVMWED SYajW 31-31 DQ ACCOUNTING OFF[CEllk� Date � <br /> EH W69 FF.VK FOR..M.doc Rev.07/07r99 <br />