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SAN JOAQUIN COUNTY <br />AL HEALTH DIVISION <br />I FORM (EH 00 69) <br />LJ New EH Pro mnt at Existin Facility <br />)),,,,.�,, ,�,. <br />J211Ctcw EH Pro ram and New Facility <br />Facility ID 001A-71) - Program Record ID ..- <br />Facility Address422C} �/YLMte1rc;-Z Det g1tt� i'P�l'tu.! Gtr <br />(Please Check the appropriate description and specify size. number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />Cl Retail Market ---Square footage ❑ with Mcat Market only <br />❑ Mobile Food Vehicle -----Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑TemporaryFoodFacility----Datesofoperation from <br />❑ Special Event - Dates of operation ' from <br />DAIRY PROGRAM (2000) <br />Food Handlers Course required: Yrs ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to ❑ Ice Plant <br />tc ❑ Producestand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPAState Facility Surcharge (2399) <br />HAZ OUS WASTE PROGRAM (2200) _ <br />❑ Hazardous Waste Generator ---------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Pemtit-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 Farms <br />HOUSING PROGRAM (2400) <br />❑ Hotcl/Motel----Number of Units ❑ Jail or Exempt Institution —Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Anplication 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 Remcdi iii pte <br />RECREATIONAL HEALTH PROGRAM (3600)- RECMENT <br />Number ofPools/Spas at Facility [3 pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathiug Ld/e6 <br />VECTOR CONTROL PROGRAM (4000) DEC <br />C1Poultry Farm --Maximum number of birds ❑ Kenge�.N 1 X ZOoo <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ENVIRpBL O CUlALT t SCOIJNTY <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics$'i� HEAL? p�ESiOf� <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 Landrdl 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 -112 - 10 ------ ❑ 11 - 60 ---❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS F.110069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACTPERSON <br />FEE <br />n, DU <br />❑ Surcharge FEE <br />rINSPECTOR # � 1 PEIWITVALID to <br />W Check# i¢D� AMOUNT PAID T f /Q. <br />.,Cash REVIEWED BY ACCOUNTING 01TICE <br />EH 0:69 PINK FORM.doc <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE# <br />Date <br />Re. _ n7M7/Oo <br />