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S,A.N JOAQUIN COUNT . _.4VIRONMENTAL HEALTH DI -V _-_JN NIASTERFILE RECORD LNFORNLATION F RM (EH 00 �y9.) ❑ New EH Program at-);�- §bng Facility �4 ew EH Pfogtarn arfd`iVew Facility �l Facility ID Facility Address f_� c m Record ED (Please Check the appropriate desc iptio and specify size, number of units and pert FOOD PROGRAM (1600) ❑ Restaurant; Searing Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Mobile Food Vehicle -----Make Vehicle Type _ Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type — Registration # License # _ ❑ Temporary Food Facility ----Dates ofoperarion from ❑ Special Event - Dates of operation from to_ DAIRY PROGRAM (2000) nent information.) Food Handlers Course required: (V,'Sbll t o ❑. ❑Vending Machines —Number of Units Cl Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # E ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head 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) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste XABOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST_ UNDERGROUND STORAGE TANK (UST) PROGRAM (3300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/ivlotel------- Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of PooWSpas at Facility Cl 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 (4100) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site Cl 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 ❑ Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM (4500) C3 Primary Care ❑ Acute Care C1 Skilled Nursing C1 Large Generator C3 Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2 - 10 --- ❑ 1 t - 60 — C2 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMgRGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON / Gl / Day P ' ,r - ��/ /, Night Ph PROGRAM ELEMENT 1 ,tel' �� FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR # '� PER vIIT VALID to ❑ Food Handler ❑ Check # A,NIO[Jf PAID Date INVOICE # C3 Cash REVIEWED BY y ACCOUNTING OFFICE Date EH 0069 PINK FORM.doc Rev. 07/07i99