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SAN J'OAQUIN COUNTY RONMENTAL HEALTH DI I N N ASTERFILE RECORD L FFORINLkTION FO (EH 00 69) ) ❑ New EH Program at Existing Facility New EH Pro am and New Facilitya Facility ID 00/;�_5'7 PrograpRe ordID IZC) 1,03 4p Facility Address C, (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: , YEs ❑ No ❑ C1 Commissary C1 Dry storage only C3 with Food Preparation ❑Vending(Machines--Number of Units_- ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ ;Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility---Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to I Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ LNIilk Dispenser---Number of Containers in Multi-Plead Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator ----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Perrrl_it-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST')(2390)----Number of AST_7L____— � UNDERGROUND STORAGE TANK(UST) PROGRAM/(2300)Use UST J and B orms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee HousinglL4hor Camp Application form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment Cl UST-CAP Site ❑ Local HSV Cleanup Site ❑ NPUSEP Cleanup Site ClUIC site C1 .abandoned HW Site El non-NPL/SEP Cleanup Site ElRWQCB Cleanup Site El Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ ;Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag I CanneryWaste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd --Number of Units ❑ FarmfRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) F ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Elauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----❑ 2- 10----❑ 11 -60--❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue ftnplieation Form J EM RGENCY NOTIFICATION FOR TH15 FAC/61 AND/OR PROGRAM CONTACT PERSON 1 Gi � Day Ph L � Night Ph i PROGRAM ELEMENT FEE ❑ Surcharge FEE [] Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handier ❑ Check# AmOUNT PAID Date INVOICE# ❑ C:Lsh REVIEWED BY ACCOUNTING OFFICE Date glLflo I �EH 0069 I'[NK FORNI.doc '- Rev.07/07/99