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SAN JOAQUIN COLS ,,/ ENVIRONMENTAL HEALTH r,. . .-,.,ON <br /> N- LASTERFILE RECORD L`rFOR.NLkTION FORINI(EH 00 69) <br /> (� New EH Program at Existing Facility ❑New EH Pr am an New Facility <br /> Facility ID 5A ODI Dq 160 Program Record ID <br /> Facility Address 251"1 W• �JQSCVIt L C <br /> (Please Check the appropriate description and specify size, number of 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 ivlachines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with iVteat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration T License T Sricker# _ <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License# Sticker <br /> ❑ Temporary Food Facility--Dates of operarion from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operarion from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> ILAZARDOUS 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 1 <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C1 Hotel/hotel-------Number of Unirs P <br /> Employee Housing(2/00) Use Emplovee Housin/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL ISEP Cleanup Site ❑ UIC Site <br /> ❑ abandoned RW 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 Cl Pool 11 Spa C1 Out of Service Pool/ <br /> C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(41000) <br /> 11 Poultry Farm Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4[00) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registrarion# License# 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 ❑ Ag/Cannery Waste Site C1 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 /> C1Primary Care ❑ Acute Care C1 Skilled Nursing 11La Large Generator C1 Small Generator El 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 Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON //���� Day Ph Night Ph <br /> PROGRAm ELF NT LD FEE El Surcharge FEE ❑ Other FEE <br /> I,rSPECTOR$ / PERtitIT VALID to ❑ Food Handler <br /> ❑ Check AIMOn7 PAID(} Date INVOICE R <br /> ❑ Cash REVIEWED BY b OD ACCOLNTING OFFICE Date <br /> EH 0069 Pi`i:FOR.M.doc <br /> Rev.07/07199 <br />