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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DMSION <br /> NL LASTERFILE RECORD IINFORNL4,TION FORM(EH 00 69) <br /> ❑New EH Program at Existing Facility ew EH irograrn and New Facility <br /> Facility ID Program Record ED p5a 1 -7S 1 <br /> FacilityAddress _7950 S- 9A Rrb�(&Pcog 4-. <br /> (Please Check the appropriate description and specify size,number of units and oertVnent information.) <br /> FOOD PROGRAM(1600) _ -4_ . .. .. ... . _ <br /> ❑Restaurant: Searing CapacitySquare FootageFood Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only 11with Food Preparation ❑Ven cling Machines-NumberofUnits - - - -- <br /> ❑ Retail Market-Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type _ - Color <br /> Registration k License 0 Sticker R <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration m Licenser Sticker R <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 C1 Grade BDairy C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> H.4ZARDOUSWASTE PROGRAM(2200) ,w LO ' <br /> ,Hazardous Waste Generator----- Tons Generated Per Year _I <br /> Tiered Permitting Facility ❑ Conditionally 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 /> ❑ Hotel/ivIotel---Number of Units ❑Jail or Exempt Institution—Number of Units ' <br /> Employee Housing(2700)Use Employee Housln2/Lahor Cama Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non.NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) - <br /> ❑Tattooing(412 1) EJ Body Piercing(4120) C] permanent Cosmetics(41?2) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration>r License A! Capacity Vehideq <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Tollets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ SludgdAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site - <br /> ❑ RefuseVehicles—Numberof Units 11Dumpsters>20cuyd—Number of Units - ❑ Farm/RanchCiemupSite <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler., <br /> ❑ Transfer Stadon ❑ Veterinary Clinic ❑ Commou Storage Facility—❑ 2. 10-0 It-60-0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Aupllearfon Form - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANn/OR PROGRAM ' <br /> CONTACT PERSON .T i 1`'t t er e 2- g Day'D k�o CSS Night Ph <br /> PROGRAMELENIENT ZZ5o FEE 2' �� Surcha emelt ❑Other FEE <br /> INSPECTORYr 3� (� PERM1TVntID (N to =12 1 Y3 - ❑FoodHandIler_� <br /> ❑ Checkp rLrIOtM PADi" Date -. .. ��k�� INVOICE <br /> >i <br /> 0 cash REViEtNFD BY . Actalttra+G DFFtcE Date <br />