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SAN JOAQUIN COL-NTY _VIRONMENTAL HEALTH DIVI: N <br />NLASTERFFLE RECORD ENFOR.NLATiON FORM (EH 00 69) <br />h5 New EH Proa-ram at Existing Facility ❑flew EH Provram and New Facility <br />1 Facility ID V-A r)h Program Record IDf Rls-S(S (o ?3!v <br />Facility Address `I LVr),d 5. L11/1Lt 10( <br />(Please Check the appropriate description and specify sing <br />FOOD PROGRAM (1600) <br />and pertinent information.) <br />❑ Restaurant: Searing Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ---Square footage ❑ with Meat Market only <br />❑ ;Mobile Food Vehicle ---Make Vehicle Type — <br />Registration # License # — <br />❑ Mobile Food Prep Unit-44take Vehicle Type _ <br />Registration # License # — <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operarion from to_ <br />DAIRY PROGRAM (2000) <br />Food Handlers Course required: YEs ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker:!t <br />Kel <br />❑ Ice Plant <br />❑ Produce Stand <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 PROGRAM (2200) <br />❑ Hazardous Waste Generator ----------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Uait ❑ Permit -By -Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST 4 1-4.000 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms z-11000 <br />I - 4-D0 <br />HOUSING PROGRAM (2400) <br />❑ HoteWylotel------- Number of Units ❑ Jail or Exempt Institution'Number of Units <br />Employee Housing (2700) Use £mplovee Kousi�r�/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site Cl UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Cl Pool Cl spa C1 Out of Service PooUSpa C1 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (41000) <br />❑ Poultry Farm Maximum number of birds C3 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) [1Body Piercing (4120) C3Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />C3 Pumper Vehicle—Registration # License # Capacity Vehicle <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C1 Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site ❑ SludgelAsh 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 />C1 Primary Care El Acute Care [I Skilled Nursing C1La Large Generator C1 Small Generator ❑Limited Hauler <br />1:1 Transfer Station ❑Veterinary Clinic Cl common Storage Facility —112 - l0 C111 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue AvDlication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRANt ELEb1ENT ,;)_3q V FEE <br />INSPECTOR $ PERMIT VALID _ <br />❑ Check k A-NlO �T PAID — <br />❑ Cash REVIEWED BY Gids. I -a7-Co <br />EH 0069 PINK FOR.M.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />ACCOUNTING OFFICE <br />INVOICE R <br />Date ] n o <br />Rev. 07i07i99 <br />