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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />NL-kSTERFILE RECORD IINFORINLMON FORNI (EH 00 69) <br />stew EH Program at ExistiinngrFacility ❑New EH Program and New Facility <br />Facilitv IDF/-\ on)c ` lq I Program Record ED <br />Facility Address 2-00 vel. F , ��- S+ ,ill pff►'L <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capaciry Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ 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 <br />Registration <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event - Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />to <br />to <br />_ Color <br />Stickerm" <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ 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 -----------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit Cl Permit -By -Rule Household Hazardous Waste <br />I<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 />❑ HoteUivlotel------- Number of Units ❑ Jail or Exempt Institution Number of Units _ <br />Employee Housing (2700) Use Employee HousinelLahor 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 ❑ 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 Pools/Spas at Facility 1:1 Pool C1 Spa C1 Out of Service Pool/Spa C1 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 (412 1) 11 Body Piercing (4120) ❑Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />C3 Pumper Vehicle—Registration # License Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ---Number of Units <br />SOLID WASTE PROGRAM (4400) <br />1:1 Landfill C1 Transfer Station 11 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 ❑ FarmfRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />C1Primary Care C1 Acute Care ❑ Skilled Nursing El Large Generator C1 Small Generator C1 Limited Hauler <br />C1 Transfer Station El Veterinary Clinic ❑Common Storage Facility —❑ 2 - 10 -- ❑ I 1 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />AM <br />PROGRELENIENT_Z3"In O FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# PERMIT VALID to ❑ Food Handler <br />El Check # A -MOUNT PAID Date INVOICE # <br />C1 <br />Cash REVIEWED BY ACCOUNTING OFFICE "Z Date bq <br />Rev. 07/0-71'99 <br />EH 0069 PINK FORM.doc <br />