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SAN JOAQUIN COU NVIRONINUNTAL 11EALTY1 DrOON <br /> N AMRME RECORD INFORMATION FORM EH 00 69 <br /> ❑Ncw W ProMM at Existing Facility ONew EH Program and New Facili <br /> Ukilit <br /> y ID ".... ` ' -. ". z P aiii Re,ord - <br /> 4. <br /> Facility Address 315 S. Center Street <br /> (please Check the appropriate$escrip(lon and specify ,nymher-,of flip{and pertinent informn.) <br /> FOOQPROG (1600) <br /> 0 Restaurant: Seating Capwity Square Footage Food Handlers Course required: YES C7 No ❑ <br /> ❑ CommEmary © Dry storage only ❑with Food Preparation ❑vending Machines—Nurnbcr of Units <br /> ❑ Retail Market---Square footage ❑ with Mcat Mancct only 0 Multiple Deportrnentt ❑ Prepacksggeed Goocls Only <br /> CJ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicic Type Color <br /> Registration If Li"nse fl SriClCer# <br /> ❑ Terop-erary Food Facility----Dates of operation from to ❑ Ice Plant <br /> ❑ Sp.ciii Event - Dates of operation fmm t0 ❑ Produce Stand <br /> yAlRy pROG�i (2000) <br /> ❑ Grade A Dairy ❑ Gride B Dairy Cl Milk Dispenser—Number of Containers in Multi-Head Unit <br /> cuEA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Wave Generator--------------___Tons Genctated Per Year <br /> Tfcred Permitdng Facility © Conditionally AUthori2exl(CA) 0 Conditionally Exempt(CE) <br /> 0 Permit-By-Rule Fixed Unit ❑ Permit-lay-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACLL.ITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK((SST)PROGRAM(2300)Use IIST A and B forms <br /> HO sING rgq RAM(2400) <br /> ❑ HotellMotd Number of Units EJ Jail or Exempt fr rtitution--Number of Units <br /> r-mployee tionsint(2700)Use,Emg1ovre Horrr'no/Lrbnr Camra,4npFonn <br /> 31TE MITtGATMN(2900) NJEt:'1 O CONTRO 000) <br /> El Environypentil Assessment ❑UST-CAP Site ❑Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site LI Witter Quality Remediation Stre <br /> RE REATIONAL HEALPROGRAM(3600) <br /> Number of Pools/Sp"at Facility ❑ Pool ❑ Spa ❑ out of service Poot/Spa ❑ Natural bathing Area <br /> VE 1411 CONYRt?L PRt3C�1tAM(4000) <br /> LJ Poultry Farm Maximum number of birds 0 Kennel <br /> TA (4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WA4TE PRO RAM(4200) <br /> ❑ Pumper Vehide—Retistration 4 License 9 Capacity Vebide# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Cbemical Toilets------Number of Units <br /> SOLID WASTE PR (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site © Sludgt/Ash Site <br /> El Waste Tire Fietllty ❑ Compost Facility ❑ Pr0cess/ReeyC1C Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Nornber of Units ❑ Dumpsters>20 cu yd ----Nurnbtr of Units ❑ Farm/Ranch Cleanup Site <br /> MFIDICAL WAM PROGRAPA(4500) <br /> CI Primary Care ❑ Acute Care 0 Skilled Nursing CJ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic 0 Common Storage Facility---Q 2- 10 1 1 -40-----❑ >6o generarors <br /> PUBLIC WATER SYSTEM PROPRAM(46W)Use PWS E90069 Blue Application Form <br /> EMERGttNC'y_NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE D SnrchArgeFet: ❑ Other FEE <br /> INSPECTOR 0 PERMiT VALID to o Food Handler <br /> ❑ Ct,eck tt AMOUNT PAID Date INVOICE# <br /> ❑ Cash REvit:ww BY ACCOUN NC OFFICE Date <br /> EH 001,9 PINK.FOP-Vf.dtx Rev.07Azl99 <br />