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JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Progr m and New Facility <br />Facility ID �� � � � Pro ram Record ID <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and e <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity_ Square Footage Foo <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation live <br />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mul <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from to I�— <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000)�I <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -I <br />ECaHazardous Materials Business Plan (1900) Number of chemicals: A— <br />❑ lARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2: <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------Number of Units ❑ Jail or Ezerr <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CON <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Clear <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility_ ❑ Pool ❑ Spa ❑ Out lof E <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # C <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fac <br />❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd <br />MEDICAL WASTE PROGRAM (4500) i <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generato <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicati< <br />Handlers Course required: YES ❑ No ❑ <br />(ding Machines Number of Units <br />Die Departments ❑ Prepackaged Goods Only <br />Sticker # <br />_ ❑ Ice Plant ❑ Produce Stand <br />❑CFO ❑A❑B <br />of Containers in Multi -Head Unit_ <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />Institution ----Number of <br />20L (3000) <br />❑ NPL/SEP Cleanup Site ❑ UIC Site <br />p Site ❑ Water Quality Remediation Site <br />Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Body Art Facility -Single Use (4120) <br />❑ Body Art -Temp Event Mobile Facility (4131) <br />)acity Vehicle # <br />Toilets ----Number of Units <br />❑ Sludge/Ash Site <br />y ❑ CIA Landfill Site <br />of units) ❑ Farm/Ranch Cleanup Site <br />❑ Small Generator ❑ Limited Hauler <br />2-10 ❑ 11 - 60 ❑ > 60 generators <br />Form <br />CONTACT PERSON C Day Ph Night Ph <br />PROGRAMELEME-�N�7El , FEE ` JtD ❑ Surcharge FEE Other FEE <br />p <br />INSPECTOR# �— PERMIT VALID t0 ❑ Food Handler <br />❑ Check# AMOUNT PAID Date' I ' INVOICE# X70 3q!� <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE <br />48-02-034 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />