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SAN JOAQUIN COUN i 7' WIRONMENTAL HEALTH DTTTWN <br />AASTERFILE RECORD LIFWNLATION FORM (EH 00 69) <br />❑ New EH Pro am at Existing Facilitv ❑New EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />11 Restaurant: Seating Capaciry Square Footage Food Handlers Course required: Yes ❑ 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 Type 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 />❑Milk Dispenser—Number of Containers in Multi -Head Unit <br />C] Grade A Dairy C1 Grade B Dairy <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 />YaBOVEGROUND 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 />❑ Jai! or Exempt Institution Number of Units <br />11 HotellMotel-------Number of Units <br />Employee Housing (2700) Use Employee Houcinmp Application 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 Cl Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 11Pool ❑ Spa C:1 Out of Service Pool/Spa C1 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Kennel <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />11 Tattooing (4121) C1 Body Piercing (4120) [1 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />C3 Pumper Vehicle—Registration # <br />License # CapacityVehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C3 Landfill C1 Transfer Station C1 Ag / Cannery Waste Site El Sludge/Ash Site <br />❑ Process/Recycle cle Facility ❑ CIA Landfill Site <br />11 Waste Tire Facility C3 Compost Facility y ❑Fat-m/Ranch Cleanup Site <br />C3 Refuse Vehicles —Number of Units [IDumpsters > 20 cu yd --Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />C3 Primary Care C3 Acute Care C1 Skilled Nursing 13 Large Generator [1 Small Generator C1 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ '_ - 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 PERSON Day Ph Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID to [3 Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE � Date <br />Rev. 07/07/99 <br />EH 0069 PINI: FORM.doc <br />