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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV SION <br /> NL-kSTERFILE RECORD LNFORtiLaTION FORM(EH 00 69) <br /> _Z&,New EH Program at Existing, Facility ❑New EH ProJram and New Facility, <br /> r_ ID 0'( i''„ fh'G <br /> Facility ID 0 Program Record �,= <br /> Facility Address erg` S , 0 Oh- <br /> (Please Check the appropriate description and specify sing number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Searing Capacity_ Square Footage Food Handlers Course required: YEs C3 No 11 <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 Ty Color <br /> Registration# License# Sticker# <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 ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRA.NI(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 FACILITY(AST)(2390)--Number of AST _ <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteU vlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C1 UST-CAP Site C1 Local RW Cleanup Site C1NPLISEP Cleanup Site C1 UIC Site <br /> ❑ .abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility Cl Pool 11 Spa C1Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) 11 Body Piercing(4120) ❑ Permanent Cosmetics(1122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# License# CapacityVehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ SludgelAsh Site <br /> C1 Landfill C1 Transfer Station C1 Ag/Cannery Waste Site 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 ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11Primary Care C1 Acute Care El Skilled Nursing 13La Large Generator C1 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10---❑ 11 -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSONDay Ph Night Ph <br /> PROGRAM ELEMENT _�nn^ FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERNIrr VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE r"r <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date P,�'/1--3bp <br /> Rev.07/07199 <br /> EH 0069 P1NK FOR.M.doc <br />