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S AN JOAQUIN COUNTY ENVIRONNNIENTAL HEALTH DIVISION <br /> NL-kSTERF LE RECORD ViFORNL-,TION FORti1(EH 00 69) <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID Program Record ID <br /> FacilityAddress (�gM e i IOI be f-abIli 'j <br /> (Please Check the appropriate description and specify sizes number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C3 Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yes C3 No C3 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration# License Sticker <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker T <br /> ❑ Temporary Food Facility---Dates of operation from to ❑ Ice Plant <br /> [ISpecial Event - Dates of operation from to C3 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGR-ANI(2200) <br /> ❑ Hazardous Waste Generator ----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fined Uait ❑ Permit-By-Rule Household Hazardous Waste <br /> 2 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 /> ❑ <br /> C1 HoteUylotel-------Number of Units Jail or Exempt Institution Number of Units _ <br /> Employee Housing(2700) Use Emplovee Housin/Labor Camp Aoolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Cl Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site 11NPL/SEP Cleanup Site El UIC Site <br /> ❑ .Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ClPool [I spa C1 Out of Service PooUSpa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds [1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C3 Tattooing(4121) ❑ Body Piercing(4120) [1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle—Registration R License Capacity Vehicle r <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units _ <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill Waste Site ❑ Sludge/Ash Site <br /> ❑ Transfer Station ❑ Ag/Cannery b <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd--Number of Units Cl Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 1:1 Primary Care C1 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited Hstors <br /> ❑ Transfer Station El Veterinary Clinic El Common Storage Facility —❑ 2- 10 C311 -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Apalieation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRANIELEti1ENT 390 FEE 11Surcha be FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE m — <br /> ❑ Cash REv VFD BY I T� ACCOUNTING OFFICE Date <br /> Rev.07/07199 <br /> EH R <br /> 6069 PINK FOM.doc <br />