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` SAN JOAQUIN COUNTY ENVIROlYNLENTAL HEALTH DIVISION <br /> NL IASTERFILE RECORD INFO FO 1(EH 00 69) <br /> C3New EH Pro at Existing Facility <br /> New EH Program and New Facility <br /> Facili ID Program Record ID <br /> Facility Address V30—N <br /> CTG�"S�E� S ��w�`(CrGC,d C-C• ��J1J� <br /> (Please Check the appropriate description and specify size.number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: Yes❑ No❑ <br /> El Restaurant: Seating Capacity Square ❑Vending iVlachines—Number of Units <br /> C] Commissary C1 Dry storage only ❑ with Food Preparation <br /> C1 Retail Market---Square footage <br /> Cl with Meat Market only ❑ Multiple Departments C1 Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make License# Sticker# <br /> Registration+ Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ liilk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy 11 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> FLaZARDOUS WASTE PROGRAi __Tons Generated Per Year <br /> C1 Hazardous Waste Generator------------- y Exempt(❑ Conditionall t CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) <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 /> ❑ Jailor Exempt institution Number of Units <br /> C] HoteUivlotel-------Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Apolicatioa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> NEP Cleanu <br /> C1 Environmental Assessment C3 UST-CAP Site ❑ S°te 1�CCRWQCB Cleanupup Site ❑Sit p Site PLS❑ Water Quality Reme❑diat on Site <br /> C1 Abandoned HW Site C1 non-NPL/SEP Cleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) C] Natural Bathing Area <br /> Number of Fools/Spas at Facility C1Pool ❑ Spa C] Out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ kennel <br /> ❑ Poultry Farm � Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# ❑ Chemical Toilets Number of Units <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) 1 Waste Site ❑ Sludge/Ash Site <br /> ❑ Transfer Station ❑ Ag/Cannery <br /> ❑ Landfill El CIA Landrill Site <br /> ❑ Process/Recycle Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Waste Tire Facility C] Compost Facility ElDumpsters>20 cu yd—`lumber of Units__ <br /> C1 Refuse Vehicles—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> [I Primary Care ❑ Acute Care C1Skilled Nursing C1 Large Generator❑ Common Storage Facility —❑ 2- 10 ❑ 11 -60---❑>60 generators <br /> C1Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON - [Iother FEE <br /> n ❑Surcharge FEE <br /> rPROG7R,k,MELEN1ENT d — FEE to ❑ Food HandlerPE S v� INVOICE#A,rtOU,`T PAID Date <br /> Date <br /> REVIEWED BY <br /> ACCOuNMG OFFICE v.07/07"99 <br />