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SAN JOAQUIN COUNTY ENVIRONME ENTAL HEALTH DIVISION IVASTERFILE RECORD 01FORMATION FORM (EH 00 69) New EH Pro at Existing Facility ❑New EH Program and New Facility FacilityID (%� SY7 (% Program Record ID I P— 6 Facility Address 13 3 D p P- o sin -fa y( AY-) (Please Check the appropriate description and specify size• number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Searing 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 Cl Mobile Food Vehicle. ---Make Registration # ❑ Mobile Food Prep Unit --Make Registration # ❑ Temporary Food Facility --Dates of operation fi ❑ Special Event - Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Vehicle Type Color License # Sticker # Vehicle Type Color _ ❑ Ice Plant ❑ Produce Stand tj 2QI ❑ Milk spenser—� lumber of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) r ❑ 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 TANK FACILITY (AST) (2390)—Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST,4 and B forms HOUSING PROGRAM (2400) C1 HoteVNlotel------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing (2700) Use Emnloyee Hourin/Lahor Camo Annlicatiart 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 ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds _ TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Permanent Cosmetics (4122) ❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Spa ❑ Out or Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel LIQUID WASTE PROGRAM (4200) Vehicle# El Pumper Vehicle—Registration # License # Capacity ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units_ SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash e/Ash Site ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste lily g ❑ Process/Recycle Facility El CIA Landfill Site ❑ Waste Tire Facility ❑ Compost Facility ❑ FarmfRanch Cleanup Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters> 20 cu yd —Number of Units MEDICAL WASTE PROGRAM (4500) rsing ❑Large Generator ❑Small Generator ❑ LimitednHauler ❑ Priary Care ❑ Acute Care ❑ Skilled Nu ❑ l l - 60 —0❑ Transfer Station ❑ Veterinary Clinic [I Common Storage Facility —❑ 2 - 10 — 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue A¢nlication Form - n EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON �gr lD S Day Ph aL O z 1� Night Ph PROGRAM ELEMENT�L�� 1 FEE _ INSPECTOR# .%�[:j--- PENT VALID ❑Check# AMOUNT PAID ❑ Cash REVIEWED BY EH 0069 PINK FORM.doc ❑ Surcharge FEE to ACCOUNTING OFFICE ❑ Other FEE ❑ Food Handler___ INVOICE # Date Rev. 07107i99