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SAN JOAQUIN COULNTY ' _'IRONILENTAL HEALTH DIVI5- N <br />NLASTERFILE RECORD LNFORNLATION FORN1(EH 00 69) <br />New EH Program at Existin, Facil <br />[]New EH Program and New Facility M -h � ('�� <br />r� <br />Facility ID t- Q00 3g Program Record ID I r ` (� 1� <br />Facility Address Z610 e. l CXk' e L.A1 J A CT �� S 1 ► I (7i G� <br />(Please Check the appropriate description and specify sib number of units and Dertinent information.) <br />FOOD PROGRAM (1600) Chi f I) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />C1 Commissary ❑ Dry storage only El with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail itilarket --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 ", License # 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 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 />AABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST 3 <br />U.NDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/,Motel------`cumber of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee HcusbrelLabor Camp Aaolicarion Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site Cl RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Cl Pool 11 spa C1 Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (41000) <br />C1 Poultry Farm Maximum number of birds C1 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 —Registrarion T _ <br />❑ Pumper Yard <br />License R Capacity Vehicle R <br />❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C1 Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site C3 Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units C3Dumpsters > 20 cu yd —Number of Units C1FarmJRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />C1 Primary Care ❑ Acute Care C1 Skilled Nursing C1La Large Generator C1 Small Generator [I Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ It - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Applicariorr Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON_ Day Ph Night Ph <br />PROGRA.N1 ELE,r1ENT Z ✓"IO FEE — <br />INSPECTOR $ PERNirr VALID <br />❑ Check," A -MOUNT PAID <br />❑ Cash REviEWED BY 0j4, 3113§ <br />EH 0069 PrNK FOR-M.doc <br />❑ Surcha be.FEE ❑ Other FEE <br />to ❑ Food Handler___ <br />Date <br />ACCOU'rrI rG OFFICE <br />INVOICE #r --�-- <br />Date <br />Rev. 07/07i99 <br />