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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NLASTERFILE RECORD LNFORINLkTION FORM(EH 00 69) <br /> New EH Program at Existing Facility f7fNew EH Pro am and New Facility <br /> Facili ID �Z, Program Record ED <br /> Facility Address 3 Z OO 5 E L DDS Q6 O S <br /> (Please Check the appropriate description and specify size• number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: Yes C3 No 11 <br /> El Seating CapacitySquare ga <br /> ❑ Commissary ❑ Dry storage only C1 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Type Color T <br /> yp <br /> El Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License# <br /> T <br /> Ty Color <br /> ❑ Mobile Food Prep Unit--Make VehicleSticker# <br /> Registration# License# <br /> to <br /> Cl Ice Plant <br /> C3 Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> KHazardous Waste Generator ----------------------- <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ 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(orms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C] HoteUMotel-------Number of Units <br /> Employee Housing(2700) Use Employee HousinZILabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment C3 UST-CAP Site ❑ Local HW Cleanup Site 11NPL/SEP Cleanup Site C1 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) in Area <br /> Number of Pools/Spas at Facility ❑ Pool C1 Spa <br /> C3 Out of Service PooUSpa ❑ Natural Bathing <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) Capacity Vehicle# <br /> C1 Pumper Vehicle—Registration# License# P ty <br /> C1 Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> [ICIA Landfill Site <br /> C1 Waste <br /> Process/Recycle Facility Waste Tire Facility ❑ Compost Facility ❑ Fat-nr/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units ElDumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1 Primary Care C3 Acute Care ❑ Skilled Nursing ❑ Large Generator C1 Small Generator ❑ Limited Hauler <br /> [I Common Storage Facility --❑ '-- IO <br /> ❑ I l -60—❑>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph G(C� Ll — q CJS 5 Night Ph <br /> CONTACT PERSON W b ( AKI i <br /> ❑ Sharge FEE [I Other FEE <br /> PROGRAM ELEMENT 2 Z l � FEE urc ❑Food Handler�-- <br /> PERMFI•VALID to <br /> I,lSPECTOR# �1 � INVOICE# ` <br /> �nNI <br /> ❑ Check# OUNT PAID Date Date /2 <br /> C1 Cash REVM ED BY ACCOUNTING OFFICE <br /> Rev.07/07199 <br />