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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> iLkSTERFILE RECORD L FOR.tNLATION FO I(EH 00 69) <br /> C1New EH Prog=at Existing Facility ew EH Pro and New Facility <br /> Facili ID Oc D3�3 Program Record ID PR 0 Sal Sid <br /> Facility Address y OO \wy\- <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 ❑ No 11 <br /> C3 Searing Capacity Square g ❑Vendin Machines—Number of Units <br /> ❑ Commissary C1 Dry storage only El with Food Preparation g <br /> 11 Retail Market----Square footage El with Meat Market only ❑ Multiple Departments El Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make Sticker <br /> Registration R License n <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker n <br /> Registration R to C1Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to C1Produce Stand <br /> C3Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Mufti-Head Unit <br /> C1 Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> FLAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generatorrized(CA) ❑ Conditionally Exempt(CE) <br /> ----- ---------- <br /> Tiered Permitting Facility ❑ Condi6onally Autho <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 /> C1 Jail or Exempt Institution Number of Units <br /> C3 HoteUivlotel-------Number of Units <br /> mp.application Form <br /> Employee Housing(2700) Use Employee Housing/Labor Ca <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C3UST-CAPSite ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ClUIC Site <br /> C1non-NPL/SEP Cleanup Site C1RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> C1 Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) C] Out of Service Pool/Spa [3 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(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle It <br /> [I pumper Vehicle—Registration# License# p <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) , ❑ Sludge/Ash Site <br /> C1 Landfill ❑ Transfer Station 13 Ag/Cannery Waste Site C1 ❑ CIA Landfill Site <br /> Process/Recycle Facility <br /> ❑ Waste Tire Facility (ICompost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ - ❑ Small❑Generator 0 Q jt60tg d Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ 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 /> Day Ph Night Ph <br /> CONTACT PERSON <br /> ❑Surcharge FEE ❑ Other FEE <br /> FEE <br /> PROGRAM ELEMENT �� ❑ Food Handler <br /> INsPecroR# <br /> PERMIT VALID to <br /> Irrvo10E# <br /> ANfOLINT PAID Date � <br /> ❑ Check K �LyG Date J l s <br /> ❑ Cash REVIEWED BY <br /> ACCOUNTING OFFICE p7/07i99 <br />