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SAN JOAQUIN COUNTY ENVIRONMENTA% HEALTH DIVI��ON <br />- N4ARTFRM.F. RF.rORD INFORINLATION FORINI (EH 00 69) <br />VNew EH Program at Existing Facility ❑New EH Program and New Facility . <br />Facility ID � f) j) / 2-,0 <br />06Program Record ID <br />FacilityAddress 73191 S 5�OL V,&LPS _S6 <br />(Please Check the appropriate description and specify size• number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage - -Food Handlers Course required: YEsCl No ❑ <br />❑ Commissary C3Dry storage only C3with 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 # <br />❑ Temporary Food Facility --Dates of operation from to 11 Ice Plant <br />C1 SpecialEvent -Dares of operation from to C1 Produce Stand <br />DAIRY PROGRAM (2000)- <br />❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />❑ Grade A Dairy ❑ Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399) - <br />HAZARDOUS WASTE PROGRALif (2200) <br />,Hazardous Waste Generator ---------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Condirionally 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) PROGRA,',I (2300) Use UST A and B forms <br />_ <br />HOUSING PROGRAM (2400) , <br />C1 Hotellivlotel ----- —Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee ffousinglLahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />C1 Environmental Assessment 11 UST -CAP Site ❑ Local HW Cleanup Site C3NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site IL ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) C1 Natural Bathing Area <br />Number of pools/Spas at Facility 11Pool ❑Spa C1 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) ❑ Kennel <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />� ❑ Body Piercing (4120) ❑Permanent Cosmetics (4122) <br />C1 Tattooing (41) y <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash e/Ash Site <br />11 Landfill ❑Transfer Station 11 Ag /Cannery Waste Site g <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Waste Tire Facility [ICompost Facility ElFarm/Ranch Cleanup Site <br />C1Refuse Vehicles -dumber of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator C] Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic C] Common Storage Facility —❑ -' - 10 <br />❑ l 1 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue AyplicatioR Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAMELEIVIENT� 2 FEE ❑ Surcharg `FEE ❑ Other FEE <br />,IsrErrolt# Qui l 1 xnatT VALID O to <br />II Z 6 El Food Handlers <br />- Fn INVOICE # <br />13Check # A,titOtl: tT PAID <br />I� i c Date <br />Accottrrra�c Or�lca 'c' Date % t '- <br />❑ Cash REVIEWED BY Rev.OV07P99 <br />