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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NIASTERFILE RECORD Lei IFORNIATION FORNI(EH 00 69) <br /> New EH Pro am at Existing,Facility ❑New EH Pro am and New Facility <br /> Facili ID b O 2 Prooram Record ID /GUS <br /> Facility Address 0 0 5- Ao r 0 f q <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square 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 C] Prepackaged Goods Only <br /> Color T <br /> Type C1 Mobile Food Vehicle----Make VehicleSticker# <br /> Registration# License# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> C1 Ice Plant <br /> C1 Temporary Food Facility--Dates of operation from <br /> to <br /> ❑ Special Event - Dates of operation from <br /> to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ClMilk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) I q n� �a&,j& A C Z 2 -7 1 <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> I <br /> C�,Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) Cl 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 /> ❑ Hotel]Motel-------Number of Units Cl Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee FlousinglLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HtiV 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 Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C1 Tattooing(4121) 11 Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> El Pumper Vehicle—Registration# <br /> License# Capacity <br /> C1 Pumper Yard C1 Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site <br /> ❑ Landfill ❑ Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Recycle cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care El Acute Care ❑ Skilled Nursing C3 Large Generator C1 Small Generator ❑ Limited Hauler <br /> El Transfer Station C3 Veterinary Clinic C3 Common Storage Facility -- <br /> ❑ 2- 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 f M N�U O Day Ph �� — oD() Night Ph <br /> PROGRA1Vt ELEMENT 2'L <br /> // FEE 11Surcharge FEE C3Other FEE <br /> INSPECTOR# <br /> PERMIT VALID to [3 Food Handler_____--, <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ., <br /> ACCOUM <br /> ❑ Cash REVIEWED BY TNG OFFICE <br /> Rev.07/07i99 <br /> rronto nn.rt'FnRM rinc <br />