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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> N ASTERFILE RECORD IINFORINL4TION FORM(EH 00 69) <br /> New EH Prograrn at Existing Facility ❑New EH Program and New Facility <br /> Facility ID D5 1 3"'1 Program Record ED <br /> Facility Address 11 K 2 Co l o r OP- <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Nig-chines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ iVlobile Food Vehicle—Make Vehicle Type _ Color <br /> Registration R License l# Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration: License it Sticker R <br /> ❑ Temporary Food Facility--Dates of operarion 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 ❑ tylilk'Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAtit(2200) S 1 <br /> Hazardous Waste Generator--------- --Tons Generated Per Year <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 /> ❑ HoteUivlotel---Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Ho«shizlLahor Camp.tonlication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1UST-CAPSite C3 Local HW Cleanup Site C1NPL/SEP Cleanup Site C1 UIC Site <br /> ❑ Abandoned HtiV Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatioa Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of pools/Spas at Facility ❑ Pool Cl spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Kennel <br /> C1Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle <br /> ❑ Pumper Vehicle—Registration 9 License K P ty <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> :.. <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C1 Landfill ❑Transfer Station ❑egg f Cannery Waste Site b <br /> `yty <br /> ❑ Process/Re cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility [I Compost Facility ❑ Farm[Ranch Cleanup Site <br /> C1 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1 Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Geaerator ❑ Small Generator 11 Limited Hauler; <br /> ❑ Common Storage Facility—❑ 2-10 ❑ 11-60—❑>60 generators <br /> C1 Transfer Station ❑ Veterinary Clinic - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Blue Aaylication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON DaY Ph Night Ph <br /> PROGRAb1 ELEMENT <br /> 2 2 U FEE .r [ISurcharg E ❑ Other FEE <br /> INSPECTOR# 31 PERMIT VALID Z <br /> -- to Food Handler <br /> ❑ Check# AMOUNT PAM "Date _ INVOICE#, <br /> f le✓12 ?/S AccoctrrruaG 0FR �ID- Date <br /> ❑ Cash REVIEWED BY . Rrv.07107199 <br />