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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVI ,F;,q <br /> ANSTERFILE RECORD INFORMATION FORM EH 00 69 <br /> New EH Program at Existing Facility ❑New EH ProgI&NIalig.Facility <br /> acili ID (,& Pr0 am Record ID 12 S!5 `173 <br /> Facility Address o2 f i�. <br /> (Please Check the appropriate description and specify sib number of units and pertinent information.) �— <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers tC urse required: YES 13 No [311Mac <br /> Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendipg h' —Number of Units <br /> ❑ Retail Market---Square footage ❑with Meat Market only ❑ Multiple Dep ents ❑ 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 /> ❑ 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_ 000 — /r 5'o C) A". <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms / — ,�50 —�O C) <br /> HOUSING PROGRAM(2400) !.A6 �A-3t'�lr j't-.a✓. <br /> WmHotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> ployee Housing(2700) Use Employee Housing/Labor Camp 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 ❑ 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(4121) ❑ 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 ❑ Farm/Ranch 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- i o----❑ 11 -60--[3 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> ONTACT PERSONDay Ph Night Ph <br /> PROGRAM ELEMENT h)I FEE 11/1nn ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 0�� PERMITVALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> El Cash REVIEWED BY ACCOUNTING OFFICE Date 36 y <br /> EH 0069 PINK FORM.doc Rev.07/07/99 <br />