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S AN JOAQUIN COUNTY E-IRONNNIENTAL HEALTH DIVIST <br />tiLASTERFILE RECORD L`iFOR.NL-kTION FORtiI (EH 00 69) <br />New EH Program at Existing Facility ❑New EH ProFaT and New Facility <br />Facility ID �-*Ar D 00 b(D Fq Program Record ID <br />Facility Address I DCID I E. R (Ca4 W L <br />(Please Check the appropriate description and spe tfy sig num <br />FOOD PROGRAM (1600) <br />and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market --Square footage ❑ with Meat Market only <br />❑ ;Mobile Food Vehicle ---Make Vehicle Type — <br />Registration R License T — <br />❑ Mobile Food Prep Unit—Make Vehicle Type _ <br />Registration T License R — <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dares of operation from to— <br />Food Handlers Course required: YEs ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker <br />Color <br />Sticker <br />R <br />C3 Ice Plant <br />❑ 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,rI (2200) <br />❑ Hazardous Waste Generator ------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Condi6onally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />'MABOVEGROUND 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 />❑ HoteVititotel------`lumber of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee Houshr /Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 Pools/Spas at Facility Cl Pool C1 Spa C1 Out of Service PooUSpa C3 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />C3 Poultry Farm Maximum number of birds C3 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />C3 Pumper Vehicle—Registration T License R Capacity Vehicle T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / 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 />C3 Primary Care C1 Acute Care ❑ Skilled Nursing C1La Large Generator C3 Small Generator 1:1 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 />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />0 Day Ph Night Ph <br />PROGRAM ELEti `IT FEE _ <br />INSPECTOR PER.titIT VALID <br />❑ Check # <br />❑ Cash <br />AMOUNT PAID <br />REViE%V'ED RY& 3 -1— <br />EH 0069 PINK FOR-M.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler__ <br />Date <br />ACCotJYrtNG OFFICE <br />INVOICE R <br />Date <br />Rev. 07i07i99 <br />