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SAN JOAQUIN COUNTY _ 'IROVNIENTAL HEALTH DIVE. i <br /> tiLASTERFELE RECORD EXFORtiLkTION FORti1(EH 00 69) <br /> EH Program at Existing FFaci^lily ❑New EH Pro -n and New Facility <br /> Facility ID 0O 10Zo Program Record ID <br /> Facility Address 1-3100 S. eas oyl B0 la <br /> (Please Check the appropriate description and specify sizes number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YFs ❑ No ❑ <br /> ❑ Commissary C1Dry storage only Clwith Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail'Ylarket—Square footage ❑ with Meat Market only Cl Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ;Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker t! <br /> ❑ Temporary Food Facility--Dates of operation from to Cl Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Nfulti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------------Toms Generated Per Year <br /> Tiered Perrnitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> Z'ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST -- <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUllotel----Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee ffousinglLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> `lumber of Pools/Spas at Facility Cl Pool Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds C1 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# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C1Landfill C1Transfer Station 11Ag/Cannery Waste Site ❑ Siudge/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/Raach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> C3 Primary Care Cl Acute Care ❑ Skilled Nursing C1La Large Generator C3 Small Generator C3 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10 ❑ It -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 ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> LNSPECTOR# Puuvrr VALID to ❑ Food Handler <br /> ❑ Check# A-MOUYr PAID Date LNVOICE <br /> ❑ <br /> Cash RFvtEwEo By Na IDO Accouvrme OMea Date <br /> EH C4)69 P[N"K FOR.M.doc VYRev.07i07i99 <br />