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S <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MI ASTERFILE RECORD INFORMATION FORM EH 00 69) <br /> New EH Pro am at Existing Facility ��Cf - -�1 l'}(_�L �'-a*i � ewEHProE=andNewFacili <br /> Facilitv ID r 0 ce j program Record II) V`'/- <br /> Facility Address r� C: ��, �I _ <br /> 1 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No ❑ <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# <br /> ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - hates 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 PROGRAM(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 8 Lorms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ ,fail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use,Employee Houcine/Labor Camp ApNicarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 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 PoolsiSpas at Facility ❑ Pool ❑ Spa [1 Out of Service Pool/Spa 13 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [I Poultry Farm—Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 1:1 Landfill [I Transfer Station 11 Ag i Cannery Waste Site ❑ Sludge/Ash Site <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 /> C1 Primary Care 13 Acute Care El Skilled Nursing EI Generator C3 Small Generator C1 Limited Hauler <br /> © Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----❑ 2- 10-------11 11 -60----CI >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application:Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON �} NIA <br /> ❑ <br /> Day Ph Night Ph <br /> PROGRAM ELEMENT JCS f FEE /l'� /� ❑ Surcharge FEE Other FEE <br /> INSPECTOR# a2a - PERMrr VALID to ❑ Food Handier_r <br /> ❑ Check# AMOUNT P AID _ D OICE# 1 <br /> El Cash RCVCEWED BY - -- ------ - ACCOUNTING OFFICE _. J '� 00 <br /> ne Rev.07/07199 <br /> F1 0069 PIINK FOR.AIdac ;:: <br />