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SAN JOAQUIN COUNT NVIRONNIENTAL HEALTH DI- ON <br />1VLASTERFILE RECORD LNFORNLATION FORNI (EH 00 69) <br />❑ New EH Program at Existing Facility []New EH Ploeram and New Facilitv <br />Facility ID <br />Program Record ED <br />Facility Address <br />�v <br />(Please Check the appropriate description and specify size, number of units and Dert <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑ Retail Market ----Square footage <br />❑ with Meat Market only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type _ <br />Registration # <br />License # <br />C3 Mobile Food Prep Unit --Make <br />_ <br />Vehicle Type _ <br />Registration # <br />License # <br />_ <br />❑ Temporary Food Facility ---Dates of operation from <br />❑ Special Event - Dates of operation <br />from to <br />rrf <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 # <br />2 <br />❑ Ice Plant <br />❑ 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 UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------- ,lumber of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housinz/Lahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <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 C1 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 - 10 --- ❑ 11 - 60 --❑ > 60 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 <br />PROGR.avt ELEZNIENT;;%1 5 Il' FEE <br />INSPECTOR# PERMIT VALID <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED BY "J <br />Day PhtlS V 7 <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />'A U00 Night Ph <br />❑ Other FEE _ <br />❑ Food Handler <br />INVOICE # <br />Date <br />EH 0069 PINK FORA.doe Rev. 07/07/99 <br />