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SAN JOAQUIN COLS -i �"TY 71RONNLENTAL HE k= DIVI Y <br />NLASTERFILE RECORD L`IFORNLaTION FOR:NI (EH 00 69) <br />X New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID <br />Program Record ED <br />Facility Address 1` VO N , O(OGIl1V� <br />(Please Check the appropriate description and specify sij <br />FOOD PROGRAM (1600) <br />and pertinent information.) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle ---Make Vehicle Type — <br />Registration R License T — <br />❑ Mobile Food Prep Unit --Make Vehicle Type _ <br />Registration T License — <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Daces of operation from to— <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker tt <br />to <br />C3 Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ iVlilk Dispenser—Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />FLAZARDOUS 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 -Z I— <br />U`iDERGROUND STORAGE TANK (UST) PROGR NI (2300) Use USTA and B forms <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 Aoplication 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 Cl Pool El Spa C1 Out of Service PooUSpa C3 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />11 Poultry Farm Maximum number of birds C1 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 m <br />❑ Pumper Yard Cl Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C1 Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site 1:1Siudge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CW 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 />C1Primary Care C1 Acute Care C1 Skilled Nursing C1 Large Generator C3 Small Generator El Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —1:12 - 10 ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Appfication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAm ELEMENT V FEE _ <br />IVSPECTORr"r PER�trT VALID <br />❑ Check;. AIMO NT PAID _ <br />❑ Cash REV[EWED BY <br />EH 0069 PC K FORIM.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />Date <br />ACCOLXrNr, OFFICE <br />INVOICE"m <br />Date <br />Rev. 07/07199 <br />