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SAN JOAQUIN COUNT NVTRONlLENTAL HEALTH DI 'ON <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> New EH Pro at ExistingFacility ❑New EH Program and New Facility O <br /> �� 'o0 3 pp_C)5l �D7 <br /> FacilityID r Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size, tuber of units and pertinent information.} <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course reauirerl- yes ❑ No ❑ <br /> ❑ Restaurant: Searing Capacity Sq g <br /> [3 Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines--Number of Units <br /> C3 Retail Market----Square footage ❑ with Meat Market only El Multiple Departments El Prepackaged Goods Only <br /> Color Type <br /> ❑ Mobile Food Vehicle-----Make Vehicle Sticker# <br /> Registration# License <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker n <br /> ❑ Temporary Food Facility-----Dates of operation from 13 Produce Stand <br /> to <br /> to 13 Ice Plant <br /> C1Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> 13 Grade A Dairy 11 Grade S Dairy 13 Milk Dispenser---Number of Containers in Multi-Head Unit <br />+ CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Cl 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 —t <br /> !UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> C3 Hotelllvlotel-------Number of Units ❑ Jailor Exempt Institution `lumber of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp,dpplication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site Cl 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 C1 Pool ❑ Spa ❑ Out of Service Pool/Spa El Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C3 Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> a LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plaut ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site 11 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(4300) <br /> 13 Primary Care 13 Acute Care 13 Skilled Nursing 1:1 Large Generator ❑ Small Generator ❑ Limited Haus <br /> ` <br /> El Transfer Station 11 Veterinary Clinic ❑ Common Storage Facility —11 ?- 10-----© 11 -60-13ler 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENGY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Vi Day Ph Night Ph <br /> PROGRAm ELEMENT FEE +,[� ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AmOuNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date / G� <br /> EH 0069 PTNK FORM.doc ` f Rev.07107199 <br />