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SAN JOAQUIN COUNT 1 ENVIRONMENTAL HEALTH DIV 1SION <br /> NLkSTERFILE RECORD INFORiNLATION FORNI(EH 00 69) <br /> ❑New EH Program at Existing Facility New EH Program and New Facility <br /> Facility ID Program Record ED <br /> Facility Address - gsd S. R -� $r 1 D S�• <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary El Dry storage only C1 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 R <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 ❑ State FacilitySurcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> zardous 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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HotellMotel-----Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee HousinglLahor 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 Cl UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Fools/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 ❑ Kennel <br /> TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/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 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 BlueAt7plieation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON JAIM?,Q, {�2�e 2 029 - �5 DAY Ph 6 Night Ph <br /> PROGRAIM ELENI.ENT Z 2 Jro FEE 7 Ujig Surcha E ❑Other FEE <br /> INSPECTOR# PERMIT VALID to /'Z ❑Food Handler <br /> ❑ che�s<x AMOUNT Pam "Date 7C8�03 -. INVOICE# f 0 3 <br /> ❑ Cash REvmvED BY . ACCOUN-17ING OME Date <br /> EH 0069 PINK FOP-M.doe - Rev.07/07/99 <br />