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SAN JOAQUIN COUNTY Ell ONNIENTAL HEALTH DIVISS <br /> NLASTERME REQO -FMvL4T10N FORM(EH 00 69) <br /> \ew,EH Program at Existing Facility ❑New EH Pro and New Facility <br /> Facility H) � m� -7Program Record ED Y a, <br /> Facility Address e(o W. Ml ti-PLe VUS R ad. E, -flC4� Ca M o <br /> (Please Check the appropriate description and specify size, numberof units and pertinent information.) ' <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required- YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending,'machines—Number of Units <br /> ❑ Retail Jlarket—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration R License R Sticker T <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License�. Sticker p <br /> ❑ Temporary Food Facility--Dates of operation from to Cl Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Nlilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> KAZARDOUS WASTE PROGRAdI(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 /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and 6 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel----Number of Units ❑ Jailor Exempt Institution—Numberof Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camy Apolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local ITW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> ❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatioa Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm—Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration License T Capacity Vehicle R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> C1 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility C3CIrf LandillC Site <br /> 11 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units El Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ElVeterinary Clinic C1Common Storage Facility —❑ 2- IO—C3 it -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Avelicarfon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR.iot ELEJIENT­9aq0 FEE ❑ Surcharge FEE ❑ Otber F£E <br /> L`eSPECTOR: PERMIT VALID to ❑ Food Handler. <br /> ❑ Cneck K A:� onrr PAID �— Date L`tVOICF R <br /> 2p ACCOUNM;G OFFICE Date ]EXEC <br /> ❑ Cash REVIEWED BY - <br /> 'Rty.07/07,'99 <br /> EH 0069 Pr,*;K FORM.doc <br />