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SAN JOAQUIN COUNTY ENVIRONIIENTAIJ HEALTH DIVISION <br /> LvL-kSTERFILE RECORD LNFORiiNL-kU0tN FORINI(EH 00 69) <br /> nac <br /> EH Pro at Existing Facility ❑New EH Pro and New FacilityID t�k 00015 5Z— Program Record ID [Lt 5-a 15-0� <br /> Facility Address z,�3� �• VW6b?,V' fide, CA g5g5 <br /> (Please Check the appropriate description and specify jjz�!,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 ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker" <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA El State Facility Surcharge(2399) 22 1 Q,vp I I A,ylC P_ <br /> HAZARDOUS WASTE PROGRAM(2200) , �`11�� -J <br /> ❑ Hazardous Waste Generator---------------Tons Generated Per Year <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 forms <br /> HOUSING PROGRAM(2400) <br />+' ❑ Hotel/hlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housin!!/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW 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 /> 1 <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) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel 1 <br /> { <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) # <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) j <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# j <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units 1 <br /> SOLID WASTE PROGRAM(4400) t i <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA Landfill Site f <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farml] anch Cleanup Site t1 <br /> j <br /> MEDICAL WASTE PROGRAM(4500) <br /> ElPrimary Care ElAcute Care C3Skilled Nursing C1Large Generator [ISmall Generator ❑ Limited Hauler i <br /> 1 <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10 C1I 1 -60—❑>60 generators I <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 B1ueApplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR.,M ELEdIENT 221 —7 FEE ❑Surcharge FEE ❑ Other FEE <br /> I;(SPECTOR# gK qq PERMrr VALID to r ❑Food Handler — <br /> ❑ Check/* AMOUNT PAID Date INVOICE# — <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date // C — <br /> .+ <br />