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J2-01-1999 10:09AN FROM TO 15592687126 P.04 SAN JOAQUIN COUNTY EN ✓JRON1V1 ECTAL HEALTH D1 VISi__4 NIASTERF LE RECORD INFORMATION FORM EH W 69 ❑Ncw EH Proat Existinp,Fa ' itv ❑New EH and New Faetli r,acitity ID Pr' aiii Record ID" Facility Address 3422 W. Hammer Lane, suite K (Please Check the appropriate description and specify si7&It-umber pf unitg and otitirient informgdon.) FOOD PROGRAM(1600) ❑Restauraot. Searing Capacity Square Footage Food Handlers Course required: YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendtna Machines–Number of Units ❑ Retail Market----Square footace ❑ with Meat Mwkct only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vchicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicic Type Color Registration# License M Sticker y ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant ❑ Special 1%vent - Date-e 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) ❑ Hazardous Waste Generator------------- Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authori2ed(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ A13OVECROUND STORAGE TANK FACILITY(AS)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B_forms HOUSING PROGRAM(2400) ❑ Hotel/Motel---Number of Units ❑ 3211 or FXcmpt Institution--Number of Unite Employee Housing(2700)Use Em to a H091firtl9bPr Form F�Ab,1,7doned ITIGATION(2900) 1NJEM0N CONTROL(3000) nvrntal Assessment ❑ UST-CAP Site ❑ Load HW Cleanup Slte ❑NPLISEP Cleanup Site ❑ UIC Site HW Site ❑ non-NPI,/SEP Cleanup Site ❑RWQCB Clesnup Site ❑ Water Quality Remediation Site RECREATIONAL H ILL" PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) LJ Poultry Farm Maximum num"r of birds El Kennel TAT 00 BOD PIERCING PERMANeNT CO�M�-'TtC !'ROdRAM(4100) ❑ Tattooing(4121) ❑ Bodv Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WANE PROCeRAM(4200) ❑ Pumper Vehicle—Registration# License tt Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-----Number of Units SOLID WASTE P1100"M(4400) ❑ L2ndf111 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Ficwry ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Unite ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site M1rDICAL W STE 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 F170069 Blue Apnlieatton Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANU/OR PROGRAMQQ 7/7/ 73 CONTACT PERSON Day Ph Night Ph PROGRAM ELEME FEE ❑ Surcharge Fee ❑ Other FEE INSPECTOR# PERMff VALID to P ❑ Fond Handler 'Check# AMOUNT PAID Date INVOICE# ❑ Cash Rsvtewso ev 0• ACCourrrrNc OFFtes Date H 00u9 PINK FORM.doc RCS.07N7 1� FH