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SAN JOAQUIN C UNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTE E RECORD l3 iF0P1AkTI0N FORM(EH 00 69) <br /> New EH Program at Existing; aciliry ❑New EH Program and New Facility <br /> Facility ID DOv 3(0 3 Program Record ED <br /> Facility Address D <br /> Oho E L --40o Sf' <br /> (Please Check the appropriate des ription and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capa iry Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storag only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square foot ge El with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C1Mobile Food Vehicle---M e Vehicle Type Color <br /> Registration License# Sticker# <br /> ❑ Mobile Food Prep Unit--M e Vehicle Type Color <br /> Registration License# Sticker# <br /> ❑ Temporary Food Facility— Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of ope ation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> C3 Grade A Dairy ❑ Grade B Dairy C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surch roe(2399) <br /> HAZARDOUS WASTE P GRAM(2200) 5 I v� <br /> Hazardous Waste Generator----------------------Tons Generated Per Year I 6 ' <br /> Tiered Permitting F cility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STO GE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORA E TANK(UST)PROGRANI(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> C1 HoteViViotel-------Number of nits Jailor Exempt Institution Number of Units <br /> Employee Housing(2700) Use Em to ee Ko«.cirr?/Lahor Cam Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site j` ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PR GRAM(3600) <br /> Number of Pools/Spas at Facility Cl Pool ❑ Spa C1 Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRA (4000) <br /> ❑ Poultry Farm Maximu number of birds El Kennel <br /> TATTOO BODY PIERCING P RMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4 00) <br /> C3 Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(44 0) <br /> C1❑ Landfill C1 nsfer Station Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Recycle cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ mpost Facility y C3Farm/Ranch Cleanup Site <br /> C1Refuse Vehicles—Number of nits C1Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM 4500) <br /> C1 Primary Care C1 Acute are C1 Skilled Nursing ❑ Large Generator [I Small Generator 11 Limited Hauler <br /> C3 Transfer Station C1Veteri ary Clinic El Common Storage Facility—112- 10 1 l -60—❑>60 generators <br /> ❑ <br /> PUBLIC WATER SYSTEM PR GRAM(4600)Use PWS EH0069 Blue Application Form <br /> MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA,NI ELENIEN— e7 17 FEE ZOO'O L) ❑ Surcha a FEE ❑ Other FEE <br /> INSPECTOR# � $ —1 ERMiT VALID I D 1, to ❑ Food Handler <br /> ❑ Check# A, OUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWHD BY ACCOUNTING OMCE Date p / 6 r7� <br /> Rev.07107;99 <br />