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` SAN JOAQUIN COUNTY ENVIRONiMENTALHEALTH DIVISION <br /> NLASTERFELE RECORD Lei tFOR.MI ATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili ID (7`� GC 1 b0� Proaram Record ED <br /> FacilityAddress 22-`61 M cu�n 5+ 3MLtn—) Ckgt 52.05 <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 C3No El <br /> 11 Searing Capacity Square ge <br /> [I Commissary ❑ Dry storage only C3 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> C1 Mobile Food Prep Unit--Make Sticker# <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> El Temporary Food Facility--Dates of operation from El 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?.Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> FIAZARDOUS WASTE PROGRAM(2200) <br /> C1 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 /> ❑ Jail or Exempt institution Number of Units <br /> ❑ iloteUNlotel-------Number of Units <br /> Employee Housing(2700)Use Employee Houcing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> E] Environmental Assessment C1UST-CAPSite ❑ Local HW Cleanup Site C1NPL/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) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ 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(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# <br /> License# <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C1 Landfill C1 Transfer Station C3 Ag/Cannery Waste Site <br /> ❑ /Recycle Facility <br /> C3 CIA Landfill Site <br /> 11 Waste Tire Facility C1 Compost Facility Process ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units_ ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1Primary Care C1 Acute Care ❑ Skilled Nursing <br /> [I Common Storage Facility —❑ 2- 10 C3 Large Generator [I Small❑Generator 0 a> i60ige �Hauler <br /> 1:1Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0469 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ❑Surcharge FEE [I Other FEE <br /> PROGRAM ELEMENT 2( FEE ❑ Food Handler_ <br /> �4 <br /> L 1. PERMIT VALID to <br /> I;ISPECTOR# INVOICE# <br /> El Check# A,�tOUNT PAID Date <br /> ACCotKnNG OFFICE Date S <br /> ❑ Cash REVIEWED BY Rev.07/07/99 <br />