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SAN JOAQUIN COUNTY P,NVIRONMENTAL HEALTH DIVIb.JN <br />y1ASTERFILE RECORD LNFORINU ION FORM (EH 00 69) <br />"�w EH Program at Existinp Facilitv ❑New EH Program and New Facility <br />Facility ID Llll<� Q Program Record ID Pk' `�/,,r � <br />Facility Address �'7 10 -,� c -c-. -��� <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle ----Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility ---Dates of operation from <br />❑ Special Event - Dates of operation from <br />DAIRY PROGRAM (2000) <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />V <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HA A OUS WASTE PROGRAM (2200) <br />$azardous Waste Generator -----------------------Tons Generated Per Year L <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 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ HotelIMotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee HousinelLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ 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 ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO, BODY _PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Tattooing (412 1) ❑ 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) 1 <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ 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 />Cl Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ 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 />CONTACTPERSON <br />PROGRAM ELEMENT, <br />INSPECTOR # <br />❑ Check # <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph <br />Night Ph <br />L0 FEE —1:1 Surcharge FEE ElOther FEE <br />PERMIT VALID to to '? __0,DL[1 Food Handler. <br />AMOUNT PAID Date INVOICE # `� 7-3a <br />❑ Cash REVIEWED BY <br />ttt UUav riNN rvtuvt.aoc <br />ACCOUNTING OFFICE <br />�:.�i■■�i��11:t!1R� <br />