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SAN JOA UIN COUNTY OviNTY E11 <br /> �20NIMENTAL HEALTH DTVI d&I <br /> [MASTERFILE RECORD � FORIINIATION FORM(EH 00 69) <br /> r >MNew EH Program at Existing Facility_ ❑New EH Pra am and Yew FaciIi <br /> Facili LD q 2 _ Program Record ID <br /> Facility Address Cl5-715 ., i <br /> oaf V <br /> (Please Check the appropriate descripirion and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) } <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course reuuired: YES❑ No C1 <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 0 Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ 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 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 /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST { <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and R farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HSV Cleanup Site ❑ NPLJSEP 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <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 ❑ FarmlRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ 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 Ap2lication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAiM ELEMENT 2� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PEP mrr VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ' <br /> EH 0069 PINK FORM.doc WRev 67107/99 <br />