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11/21/2003 11:39 2094683- FIFTH FLUOR <br /> - PAGE 03 <br /> SAN JOAQUIN COUNTY ENVIRONAI4ENTAL HEALTH D1VIS10N� <br /> 1LASTERME RECORD F01t:YJATiON FO (JH3 00 69)' <br /> 13 New EH Program 1Nu ExistiaR Facility ew EH'pro and New Faeiliry <br /> Facility ID Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify jft�,nu mbar of units and pertinent information.) <br /> FOOD PROGRAM(1600) ' <br /> ❑Resmursut: Seating CapacitySquare Footage Food Handlers Course reouired, Yes ❑ No Q <br /> ❑ Commissary ❑ Drystorageoniy ❑ with Food Pteparadon ❑Vending Ni.A chines—Number of Units <br /> ❑ Retail Market_Square footage El with Meat Merkct only ❑ Multiple Departments ❑ Prepat kagcd Goods Only <br /> ❑ Mobde Food Vehicle—Make Vehicle Typo Color <br /> Registration# License# Sticker;$_— <br /> ❑ Mobile Food Prep Unit—Make Vehicle Typo Color_ <br /> Registruion# LicenseA _ StickcrP _ <br /> E2 Temporary Food Faeiliry—Dates ofopcmtion from to W ❑ Ice Plant <br /> ❑ Special Event - Dues of operation from to _ :Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grrde A Dairy ❑ Grade B Dairy - ❑ Milk Dispenser—Number of Containers in Multi-14.ead Unit <br /> COPA ;4 State Facility Surcbargc(2399) <br /> HAZARDOUS WASTE PROGRAM(2300) <br /> ganzardous Waste Generator---------Toos Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) Cl Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household EIMArdous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY CASI)(2390)—Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(3300)Use LISTA aprl B forms <br /> HOUSING PROGRAM(2400) <br /> Employee Housing(3700)Use Employee Hnusene/Lahor Camp AmUcatipn Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Lural JAY Cleanup Site ❑ NPLISEP Cleaaup Site 0 UlC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site Q RWQCB Cleanup Site ❑ Water Quaiity Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Sp"at Faciliry ❑ Pool ❑Spa ❑ Out of Service PonUSpa ❑ Nat,rail Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ KCI.ne1 <br /> TATTOO BOOP PIERCING- PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) .7 Permanent Cosmei ics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ Pumper Vehicle—Registradon9 License# Capacity_- Vet ick,# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Numbcr of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Trausfer Station - Cl Ag/Cannery Wastesite ❑SluditdAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProccwReeycle Facility ❑CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>30 ca yd—Number of Unit_ ❑ FarmlFao,h Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Cart Q Skilled Nursing ❑ Large Gmerator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ­13 2- 10 ---❑ it-60---11>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EA0069 81ae pyr7 Bion Form <br /> EMF GENCY MCMPICATION FOR THIS FAG LITY ANO/OR PROGRAM <br /> CONTACTPERSON U7y) /t. � �{9}7L Day Ph X77 Zb-�_ NiglttPh %v—5-6 <br /> PROCRAMEmmErM �. �-U FEZ ❑SunebatgEFEE -_ 0 Other FEE <br /> INSPECTOR# �3 PERMrr VALrn to ❑Food Handler <br /> ❑ check it AMOUNT PAM Date INVOICE 3f �-- <br /> ❑ Cash REvmwED sY ACCOtNTM OFFICE Date <br /> EH 0069 PINK FORNLdoc - Rc-r.07/o7199 <br />