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SAN JOAQUIN COU`Z T` 'IROLN 1ErTAL HEALTH DIV_ Y <br />.NL-kSTERFELE RECORD DFORYIATIOLN FORM <br />00 69) <br />19 New EH Program at Existing Faciliry ❑New EH Program and New Facility <br />I Facility ID V-A UO I M L4 -q Program Record ED I <br />Facility Address goo M055ctaie 1�60a - 156060 Sa"LO IVl <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Prepararion <br />❑Vending Machines —Number of Units <br />C3Retail Market --Square footage <br />C1with Meat Market only <br />C3 Multiple Departments C1 Prepackaged Goods Only <br />❑ 'Mobile Food Vehicle ---Make <br />Vehicle Type <br />Color <br />Registration R <br />License R <br />Sticker <br />❑ Mobile Food Prep Unit—Make <br />Vehicle Type <br />Color <br />Rea-iscrarion # <br />License # <br />Sticker <br />❑ Temporary Food Facility --Dans of operation from to <br />❑ Special Event - Dares of operation from to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Bilk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />FLAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Cond.idonaUy Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Perrrut-B Rule Household Hazardous Waste <br />)ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (3300) Use USTA and B forms <br />HOUSING PROGRAM (2400 <br />❑ Hotel/Mocel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housin /Labor Camp Aoplication 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 />Number of Pools/Spas at Facility ❑ Pool Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4-000) <br />El 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 T Capacity Vehicle T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C1 Landfill C1 Transfer Station C1 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 />F-1PrimaryCare El Acute Care C3 Skilled nursing C1 Large Generator C1 Small Generator [1 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Avolication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEXE`(T :T' 1 0 FEE / ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR PERMIT VALID to ❑ Food Handler <br />❑ Check . AMOUNT PAID Date INVOICE R <br />❑ Cash REVM ED BY C1 Y k '2) � � 31 C )o ACCOUNiTNG OFFICE Date <br />EH 0069 PWK FOR.\I.doc Rev. 07/07/99 <br />