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SAN JOAQUIN COLNT1-NVIRON1�LENTAL, HEALTH DIV <br />vLASTERFME RECUPT LNFORvLATION FORM (EH 00 69 <br />❑ :New EH Pro -ram at Existing Facilitv ❑New EH Pro am <br />Facility LD Irpromc -t,-,,�+ Proizram Record ED 1 ne <br />'ON <br />and New Facility <br />Facility Address _3-10Z LA 5 �z�c.lCioN <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restauraot: Searing Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only C1 with Food Preparation ❑Vending Machines —Number of Units <br />C1 Retail Market ---Square footage ❑ with Nteat Marker only ❑ Multiple Departments ❑ Prepackaged Goods <br />C3 Mobile Food Vebicle---Make 0.1,,Vehicle Type Color <br />Registration m License," Sticker;; <br />❑ Mobile Food Prep Unit—Nfake Vehicle Type Color <br />Registration R License T Sticker <br />❑ Temporary Food Facility --Dans of operarion from to <br />❑ Special Event - Dates of operation from to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Cl Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />FL-kZARDOUS WASTE PROGRAM (2200) <br />THazardous Waste Generator -------------------_-pons Generated Per Year G 5 <br />iered Permitting Facility ❑ Conditionally Authorized (CA) <br />C1 Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Uait ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROU`iD STORAGE TANK (UST) PROGRANI (3300) Use UST and 8 forms <br />HOUSING PROGRAM (2400) <br />❑ HoteU`Iotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (3700) Use Emplovee Housinz/Lahor Camp Aoplicatiorr Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment Cl 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 Cl Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License R Capacity Vehicle m <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 C1 Siudge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CLA 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 />11 Primary Care El Acute Care [I Skilled Nursing C1Laree Generator C3 Small Generator C1 Limited Hauler <br />❑ Transfer Station Cl Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue ADplicarion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM E�EXEENT d,;� 01' FEE — <br />INSPECTOR x V. rrDRA2,R PE,,u irr VALID <br />❑ Check, A_`1oG`NTPAID <br />❑ Cash REVIEWED BY <br />EH 0069 PrN"K FORM. <br />❑ Surcharge FEE C1Other FEE <br />to � t <br />3 "1 ❑ Food Handler_ <br />Date <br />Accou r NG OFFICE <br />INVOICE T <br />Date g <br />Rev. 07107i99 <br />