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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NIASTERFILE RECORD h IF01MNLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility []New EH Progam and New Facility <br /> I'Facility ID 060 3-731 Program Record ID l 7 U <br /> Facility Address I N. "yvr ` S911,-*f M eAlh 120 , <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing CapacitySquare 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 Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type _ Color <br /> Registration K License R Sticker r <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration; License Sticker R <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 11 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> RAZARDOUS 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 Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> U,IDERGROUND STO PAGE TAI-4K(UST)PROGR_aivl(2300)Use UST,4 and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteukNIotel---Number of Units ❑ Jailor Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee HousinzlLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> `lumber of Pools/Spas at Facility ❑ Pool Cl spa C1 Out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—May imurn 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—Registradon# License h Capacity Vehicle it <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical ToiletsNumber 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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 11 Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator 11 Limited Hasler: <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—112-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Blue Application Form <br /> EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON -nDay Ph Night Ph <br /> PROGRAAQ ELEhtENT FE <br /> G 3 E eFft❑Surcharg � T_ ❑ Other FEE <br /> Iyseecrottaf PEWIT VALID ❑Food Handler <br /> 11Check z AatifO[M PAID Date INVOICE <br /> ❑Cash Rl vt�"'M BY �tJ�= ACCOUNnNG Date <br /> MM71'99 <br />