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-� SAN JOAQUIN COUNTY E�RO\t-NIEt TAL HEALTH DIVISIO <br /> NLASTERFII E RECOOF-NLATION FORM(EH 00 69) <br /> ❑ \Cw EH Prooram at Existing,Facility 'O'New EH Program and New Facility <br /> Facility ID Program Record ED 1/G 05/!0/9A <br /> Facility Address 9006V S Ka S S0✓1 tZOa.d 1166LGV <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 ❑Veading Machines—Number of Units <br /> ❑ Retail Market—Square footage- El with Meat Market only C3Multiple Departments ClPrepackaged Goods Only <br /> ❑ `lobile Food Vehicle—Make Vehicle Type Color <br /> Registration T License T Sticker <br /> C3Mobile Food Prep Uait—Make Vehicle Type Color <br /> Registration: License 2 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) <br /> J Hazardous Waste Generator---------------Cots Generated Per Year <5'i—Dy—IS <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)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotet/Motel•---Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee flousi /Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C3 Environmental Assessment 13 UST-CAP Site ❑ Local Hw Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> ❑ .Abandoned HW Site ❑ non-NPI/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Fools/Spas at Facility ❑ Pool ❑ Spa Cl Out of Service Poouspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum numberof birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C1 Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration <br /> License Capacity Vehicle m <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) 13Sludge/Ash Site <br /> C3 Landfill ❑ Transfer Station ❑ Ag/Capnery Waste Site <br /> ❑ Process/Recycle Facility 1:1 CIA,Landfill Site <br /> ❑ Waste Tire Facility C3 Compost Facility ❑ Farm/Raach Cleanup Site <br /> C3 Refuse Vehicles—Number of Units 13Dumpsters>20 cu yd—Number of Units <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—❑ I t -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0469 Blue Avolieation Form r,{/U• O �, '7/ %/ J <br /> GEMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 2 / PR 05�(p X93 Day Ph Night Ph <br /> PROGRAMELEMENT 22211 FEE ❑ Surcharge EE ❑ Other FEE <br /> INSPECTOR - PE&%l VALID .`� 1 00 to 1.7- 3r GG El Food Handler <br /> ❑ Check# A.MOUN-r PAID —�� Date INvoiCE m--------- � <br /> ❑Cash REs/tEV/ED BY <br /> 5 DO ACCCWrIVG OFFICE Date <br /> Rev.07i07r99 <br /> EH C4069 PINK FORJt.doc <br />