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SAN JOAQUIN COC t'TY ENVIRONN'IENTAL HEALTH DIVISION lLASTERFELE RECORD IINFOR IAUON FORM (EH 00 69) ,O -New EH Proeram at Existing Facility ❑New EH Program and New Facility I Facility ID fA tl-Y)28_�3(o Procram Record ED Q f/ 0 % 1 Facility Address 5151 Ian c4 fi ('. A't/P.r'l.{,la , (Please Check the appropriate description and specify sib number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ 'Mobile Food Vehicle ----Make Vehicle Type Color Registration # License # Sticker ❑ Mobile Food Prep Unit --Make Vehicle Type Color Re;istration License # Sticker # ❑ Temporary Food Facility ---Dates of operation from to ❑ Special Event - Dates of operation from to ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator ----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) Cl Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST IPN_ UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ C1 Hotel/Motel-------Number of Units Jail or Exempt Institution Number of Units Employee Housing (2700) Use Emplovee HousinelLahor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility Cl Pool ❑ Spa C1 Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) [I Tattooing (412 t) ❑ Body Piercing (4120) C1 Permanent Cosmetics (3122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle—Registration # _ ❑ Pumper Yard License" Capacity Vehicle # ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM (4400) C3 Landfill C3 Transfer Station C3 Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd --Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care El Skilled Nursing 11La Large Generator C3 Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 -- ❑ l I - 60 —❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON PROGRA,,I ELEMENTo(�l V 1 FEE INSPECTOR # ❑ Check # ❑ Cash PERtitIT VALID Day Ph Night Ph ❑ Surcharge FEE ❑ Other FEE to ❑ Food Handler A,�/t'�ouN--T PAiD^ Date REVIEWED BY t 1p) I�I W ACCOU,MNG OFFICE EH 0069 PINK FOR.M.doc INVOICE # Date /,,V Rev. 07107i99