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SAN JOAQUIN COUNT _ _NVIRONMENTAL HEALTH DIV, --.,ON NIASTERFILE RECORD INFORI IATION FORM (EH 00 69) New EH Pro am at Existing Facility_ ❑New EH Program and New Facility Facility ID ti"k Program Record ED ? tel¢ Facility Addressr (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -----Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color Registration # License # Sticker # C3 Temporary Food Facility ----Dates of operation from to ❑Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ 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 2ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) ---Number of AST_ UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) C1 Hotel/Motel ------- Number of Units 11 Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housin!/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 Pools/Spas at Facility El Pool 11 spa ❑ Out of Service PooUSpa C1 Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # _ ❑ Pumper Yard License ❑ Package Treatment Plant ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle # ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM (1400) ❑ Landfill C3 Transfer Station 1:1 Ag / Cannery Waste Site 1:1 IA Landfill Site ndfAsh Site ❑ Waste Tire Facility C1 Compost Facility C3Process/Recycle Facility C3CCW L ❑ Refuse Vehicles --Number of Units ❑ Dumpsters >'_0 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) C1 Primary Care 13 Acute Care ❑ Skilled Nursing 11 Large Generator ❑Small Generator C3 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2 - 10 --- ❑ 1 I - 60 --❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON PROGRAM ELEMENT 1 ` FEE _ INSPECTOR# V PERMITVALID ❑ Check # AMOUNT PAID ❑ Cash REVIEWED Bl EH 0069 PINK FORM.doc Day Ph ❑ Surcharge FEE to Date 'COUNTING OFFICE Night Ph ❑ Other FEE ❑ Food Handler INVOICE # Date f 7 Rev. 07/07/99