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AdL SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DIVI . N NLASTERFTLE RECORD LNFORM.ATION FORM(EH 00 69) 0?4New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Program Record ED /, Facility Address 2500 W L o A l fty E f Lo D I (Please Check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only 11 with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ :Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation from to Cl Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) VHazardous Waste Generator----------------------Tons Generated Per Year L 5 Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Pemtit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Employee Housin✓Labor Camp Application Farm SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site ❑ .Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—i4aximum number of birds ❑ Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu,yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10--❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRdM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMrr VALID to ❑ Food Handler. ❑ Check# A�M.7o1N(�T PAID Date INVOICE# 11 Cash REVIEWEDBY(7(90 P J> 2 *O_ cCOUNTrtGOFFICE Date - EH 0069 PrNK FORM.doc �(2Q� bt.�- Rev.07/07199