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SAN JOAQUIN COLI., i ENVIRONMENTAL HEALTH L ISION NIASTERFILE RECORD INFORNLATION FORM(EH 00 69) ❑ New EH Program at Existing Facility ew EH Program and New Facility FacilitylD ePOIIa77 Program Record ID 45 S la 3a Facility Address 155 YWyWq5ZIS (Please Check the appropriate description and specify sing number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: VEs❑ No ❑ ❑Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Regisrration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Nlilk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2300) 5�41azardous Waste Generator- � -Tons Generated Per Year G Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACMTY(AST)(2390)—Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms HOUSING PROGRAM(2400) ❑ HoteUblotel------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Employee Housbt/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration# License" Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) El Landfill C3 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112- 10—❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON n.t �/�1 ay P j D -5Night Ph M 7 PROGRA��t ELEENT ,; t rZ V FEE ❑ Surcharge FEE ❑ Other FEE L`IsPECTOR# j9( log PERMIT VALID / - -62 U to /2'3 /" Oy ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE fir` 13 Cash REVrEWFDACCOI IINGOFFICE Date / (�(� Rev.07/07/99 EH 0069 PINK FORM.doc