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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVIS>ON <br /> NIASTERFrLE RECORD INFORNI ATION FORM(EH 00 69) <br /> New EH Program at Existing Facilitv ❑New EH Program and New Facility <br /> Facili ID GJ D Program Record ED <br /> FacilityAddress ( 0q L0 MeA (D� Ave , �1 <br /> �V •a'Y' SCG` <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S FootageFood Handlers Course re°uired: Yrs 12 No El <br /> luare Restaurant: Searing Capacity q <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color Type ype <br /> ❑ Mobile Food Vehicle--Make VehicleSticker <br /> Registration# License# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration <br /> License# Sticker# <br /> # ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to <br /> ❑ Special Event - Dates of operation from <br /> 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 ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator---------------Tori Generated Per Year <br /> Tiered Permitting Facility 2'E-onditionally 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/Motel-----Number of Units ❑ Jail or Exempt Institution—Number of Units _ <br /> Employee Housing(2700) Use Employee Housir /Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ UIC Site <br /> Cl .Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Cl Pumper Vehicle—Registration# License# CapacityVehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill C3 Transfer Station ❑Ag/Cannery Waste Site ❑ SludgdAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Proms/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—❑ it -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHt7069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON I Day Ph Night Ph <br /> a <br /> PROGRAM ELEMENT a3FEE 4L qo•o ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID 4�Ao 1 00 to _ ❑ Food Handler <br /> ❑ Check# AdouNT PAID Date INVOICE? — <br /> ❑ Cash REvTEwED B ACCOUNTING OFFICE Date <br /> Rev.07107i99 <br /> EH 0069 PINK F02vt.doc <br />