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SAN JOAQUIN COUNT14, aNVIRONNIENTAL HEALTH DI_,.r.ON <br /> NIASTERFH.E RECORD INFORNLATION FORM(EH 00 69) <br /> New EH Pro am at Exiissttiing Faciliry ❑New EH Program and New Factlt <br /> Facilitv ID O� Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size• number of units and pertinent info ation.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course reouired: Yes❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending Machines—Number of Units <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vebiele---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 <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dares of operation from <br /> to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> — <br /> C1 <br /> ❑ 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 /> XBOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST _�_ <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotet/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2 700) Use Employee Ho sit a/Lahor Camp rlppUcarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site C3NPUSEP 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 Cl Spa ❑ Out of Service PooVSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station El Ag/Cannery Waste Site E3 Sludge/Ash Site <br /> ❑ Process/Recycle cle Facility ' ❑ CW Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility Y <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units <br /> ❑ 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 --❑ '_- 10-- (❑,I ISI-60—❑>6,0 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAbr ELEMENT G FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# t%nPERMIT VALID to ❑ Food Handler <br /> ❑ Check It A.vIOUNT PAID Date INVOICE. ' <br /> C1n <br /> Cash REVIEWED BY ACCOUNxa OFFICE Date �- <br /> Rev.07/07i99 <br /> EH 0069 PINK FORM.doc <br />