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AM a <br /> SAN JOAQUIN COUN x ENVIRONMENTAL HEALTH DIV MON <br /> *vIASTERFILF RECORD LNFORINIATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Faciliry ❑New EH Program and New Fpacili <br /> FacilityID OW C Program Record ED P1Q0 /�42 KZ <br /> Facility Address L5-33 - a" /) ' <br /> (Please Check the appropriate description and specify sizenumberof units <br /> 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 Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ 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# <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 Dairy 11 Grade B Dairy 11 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> — <br /> i <br /> State Facility Surcharge(2399) <br /> AZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator--- --Tons Generated Per Year �RI <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> �L4 S 'CRq qqr��G,,�A0 ermit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> O ❑ ABOVEGROUND STOR&IGE ,FACILITY(ASI)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/ivlotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> F-mpluyee Housing(2700)Use Employee Hg sit glLabor 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 13 spa C3 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [I 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 /> C1 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> [I Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site Cl Sludge/Ash Site <br /> ❑ Waste Tire Faciliy ❑ Compost Facility ❑ Pmeess/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd--Number of Units <br /> ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) - <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ '_- 10--❑ 11 -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—ZQ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMrr VALID to ❑ Food Handler. <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> C3Cash REVIEWED BY ACCOUNTNG OFFICE Date <br /> /-,-��,�D / Rev.07/07199 <br /> EH 0069 PINK FORM.doc / / <br />