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SAN JOAQUIN COUNTY ENVIRONMENTAL;HEALTH DIVISION <br /> 11ASTERFT_LE RECORD L IFOILNIATION FORM(EH 00 69) <br /> ❑ New EH Pro am at Existing Facility New EH Program and New Facility <br /> Facili ID Program Record ED X <br /> Facility Address ( 1-7 SD fAA NkJ Qu' <br /> (Please Check the appropriate description and specify sig number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes C1 No C1 <br /> El Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending ivlachines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C3 Mobile Type Color Mobile Food Vehicle----Make Sticker# <br /> Registration# License# <br /> , <br /> C1 Mobile Food Prep Unit--Make Vehicle Type Color Sticker� <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C1 'Milk <br /> Grade A Dairy C1 Grade B Dairy ilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> fLAZARDOUS WASTE PROGRAiNI(2200) <br /> ❑ Hazardous Waste Generator---------------------Tons Generated Per Year <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 FACILI'T'Y(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> ❑ IToteViYlotel-------Number of Units <br /> Employee housing(2700) Use Employee Housin7/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment C1W UST-CAP Site ❑ Local HCleanup Site C1 L14PUSEP Cleanup Site C1UIC Site <br /> Clon-NPL/SEP Cleanup Site C1RWQCB Cleanup Site F-1WaterQuality Remediation Site <br /> C1 Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) [I Natural Bathing Area <br /> Number of Pools/Spas at Facility 11 Pool C1 Spa <br /> C] Out of Service PooVSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) 13 Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> # <br /> ❑ Pumper Vehicle—Registration <br /> License# Capacity <br /> ❑ Pumper Yard C1 Package Treatment Plant Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Ftecycle Facility <br /> ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility C1Farm/Ranch Cleanup Site <br /> C3Refuse Vehicles—Number of Units C1Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care El Acute Care ❑ Skilled Nursing C1 Large Generator C] Small Generator ❑ jtmtt�ed H ?orsr <br /> C1 Transfer Station ❑ Veterinary Clinic <br /> [I Common Storage Facility—❑ 2- 10-- ❑ 11 -60—060 <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON GA'`f w A V—l': Day Ph Night Ph <br /> �— FEE ❑Surcharge FEE ❑ Other FEE <br /> PROGRAiVi ELEh1ENT Z �(� " <br /> [I Food Handler�— <br /> INSPECroR# 3 l PERMIT VALID to <br /> ❑ Check# <br /> AMOUNT PAID Date INVOICE# <br /> ACCOUMING OFFICE Date <br /> [3 <br /> Cash REVIEWED BY Rev.07/07/99 <br /> Fu W69 PINK FORM.doc <br />