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SAN JOAQUIN COUNTY TY ENVIRONiMENTAL HEALTH DIVISION <br /> HASTE RECORD II1FORNLATION FOPIM(EH 00 69) <br /> ❑ New EH Program at Existin Fciliry ew EH Pro and New Facility <br /> FacilityID D yaS Program Record ID <br /> Facility Address _3,3 f. <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: Yes ❑ No 11 <br /> C1 Commissary El Dry storageonly C1 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market--Square foot ge ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Mak Vehicle Type Color <br /> Registration License# Sticker# <br /> ❑ Mobile Food Prep Unit--Mak Vehicle Type Color <br /> Registration P 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 ❑ State Facility Surcharge(2399) - <br /> HAZARDOUS WASTE PROGRAM(2200) C -S 4yryN <br /> Hazardous Wast Generator--------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Condidonally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STO GE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORA SE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> C1C1 Hotel/Motel-------Number of nits Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Em 71ovee Hou.cinelLabor Camodpolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1UST-CAPSite ❑ Local HW Cleanup Site ❑ YPWSEP Cleanup Site ❑ UIC Site <br /> C1 Abandoned HW`Site C1 non-NPL/SEP Cleanup Site C1RWQCB Cleanup Site `1' ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility Cl Pool El Spa C1 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROG M(4000) <br /> ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY P I ERC I NGj3ERM ANENT COSMETIC PROGRAM(4100) <br /> C1 Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetic(4122) <br /> LIQUID WASTE PROGRAM( 200) <br /> ❑ Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM( 00) <br /> C11:1 Landfill C1 Transfer Station Ag!Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Rec cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility Y h <br /> C1 Refuse Vehicles—Number o Units C1Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRA (4500) <br /> C1 Primary Care 13Acu a Care El Skilled Nursing ❑ Large Generator C1 Small Generator ❑ Limited Hauler <br /> C1 Transfer Station ❑ Vet rinary Clinic ❑ Common Storage Facility —E] 2- 10 ❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E9006 Blue Amlication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> lgy-PROGRAM ELENIENT Z FEE 200 ,00 Surcharge FEE (7. �J ❑ Other FEE <br /> I'4SPECTOR# 00-7 PERMIT VALIDI -D to I" d ❑ Food Handler_____—, <br /> ❑ Check# MOUNT PAID Date /DINVOICE#, 1D — <br /> ❑ Cash REVTEWED s ACCOUNTING OFFICE Date <br /> Rev.07/07i99 <br />