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r <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> ILaSTERFII�E RECORD It`1FOR�tiLATION FORM(EH 00 69) <br /> Iew EH Prograrn and New Facility 71 <br /> ❑ New EH Program at Existing Facility _ <br /> Facility ID /1 uU 1 t 5�l t� Program Record ED <br /> Facility Address 4120 -Gz � <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) 11 <br /> Square Footage Food Handlers Course required: Yes No <br /> ❑ Restaurant: Searing Capacity q g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> 11 Retail Market ---Square footage ❑ with Meat Market only [I Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> El Mobile Food Vehicle---Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> El Mobile Food Prep Unit--Make License# Sticker <br /> Registration# to C1 Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑to Produce Stand <br /> C1Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C3 Grade?.Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) ZZ <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generator--------------------- nally Exempt(CE) <br /> Tiered Permitting Facility C1 ❑ Conditio <br /> Conditionally Authorized(CA) ❑ PermitRule Household Hazardous Waste <br /> C1Permit-By-RuleFixed Unit y" <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 /> El jail or Exempt Institution Number of Units <br /> C] HoteuMotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Lahormp rtpplicatian Form <br /> Ca <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Cleanup Site [IUIC Site <br /> El Environmental Assessment C1 Qon yP�SEP Cleanup Slte- AP Site1 ❑CRWQCB Cleanup leanup Site ❑Sit P�S❑PWater Quality Remediation Site <br /> C1 Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ put of Service PooUSpa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility Cl Pool ❑ Spa <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 /> ❑ Pumper Vehicle—Registration# <br /> License# P <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site C1rocesEl CIA Landfill Site <br /> Ps/Recycle Facility <br /> C1 Waste Tire Facility C1 Compost Facility C1Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units C1 Dumpsters>30 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ <br /> C1 Skilled Nursing Large Generator C3 Small Generator ❑ Limited Hauler <br /> ❑ Acute Care <br /> ❑ Primary Care ❑ , _ 1p ❑ I 1 -60—❑>60 generators <br /> C1 Transfer Station ❑ Veterinary Clinic <br /> C] Common Storage Facility — <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Night Ph <br /> Day Ph <br /> CONTACT PERSON [3 Other FEE <br /> ❑ Surcharge FEE <br /> PROGRA,,M ELENIENT Z 1 FEE ❑ Food Handler�� <br /> PERMIT VALID to <br /> INSPECTOR# jr(VOICE# ` <br /> AMOUNT PAID Date <br /> ❑ Check k Date 3 <br /> ❑ Cash REVIEWED BY <br /> ACCOUNTING OFFICE Ray.07/07x99 <br />