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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DIMS ON ILASTERFIELE RECORD L 1FORVLaTION FORM(EH 00 69) New EH Program at Existing, Facility ❑New EH Program and New Facility Q Facili ID Program Record ED / -0s/6,S 7`7 Facility Address LSU t,% -A�� L0A i (Please Check the appropriate description and specify size,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 Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation from to Cl Ice Plant ❑ Special Event - Dates of operation from to ❑ 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) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TAiNK FACILITY(AST)(2390)—Number of AST I UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST.A and Bforms HOUSING PROGRAM(2400) ❑ HoteUtilotel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee HousinJLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 ❑ 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) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ 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 ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112- 10--❑ I 1 -60—13>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT jZ?2.._q_DL FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERmrr VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REWE«/ED BY ACCOUNTING OFFICE �� Date /1 1�2 EH 0069 PINK FORM.doc Rev.07/07/99