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S AN JOAQUIN' COUNT` Y ;ONtiLENTAL HEALTH DIvo) <br /> NL.kSTERFELE RECORD LNFOR:tiL-,TION1 FORM(EH 00 69) <br /> New EH Pro- at 5.<istia�Facility ❑'New EH Pro am and New Facility <br /> Facility ID IFA I D I Program Record ID <br /> Facility Address qq 6i Ci S. AtAsfw-) 1900A , M ay*-Oa, <br /> (Please Check the appropriate description and specify sib number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br /> Cl Commissary F-1Drystorage only C1 with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market---Square footage ❑ with�14ear Market only ❑ Multiple Departments Cl Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License T Sticker <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License K Sticker T <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ 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 iviulti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> FLaZARDOUS 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 Uait ❑ Permit-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST 3 _ <br /> UN, DERGROnL D STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution 'Number of Units <br /> Employee Housing(2700) Use Emptovee HoushrzlLabor Camp loalication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C1UST-CAPSite ❑ Local HW Cleanup Site C1NPL/SEP Cleanup Site Cl 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 [I spa C1 Out of Service Pool/S ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle-Registration T License# Capacity Vehicle R <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 ❑ 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 /> C1 Primary Care C1 Acute Care El Skilled Nursing ❑ Large Generator C1 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 C1i 1 -60—11>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 /> PROGRAbI ELEMENT 2 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR'# PERmrr VALID to ❑ Food Handler___--. <br /> C1 Check# AIMOU`r T PAID Date INVOICE R <br /> ❑ Cash REVTEW`ED BY AccotrvraJc OFFICE Date / <br /> Rev.07/07i99 <br /> EH 0069 PI`K FOR-M.doc IQ <br />