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SAN JOAQUIN COUNT _—.4VIRONNIENTAL HEALTH DIV.- N <br />NIASTERFILE RECORD L 1FORtiLMON FORM (EH 00 69) <br />❑ New EH Program at Existing Facilitv []New EH Pro am and New Facil <br />Facility ID Program Record ID Ti'n <br />Facility Address &4Ul ar %611L_ k <br />(Please Check the appropriate description and specify size, n <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 # License # _ <br />❑ Mobile Food Prep Unit --Make Vehicle Type _ <br />Registration # License # <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event - Dates of operation from to_ <br />dq G <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 />to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Nlilk 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 I� <br />UNDERGROUND STORAGE TANK (UST) PROGRaNI (2300) Use UST,4 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 HousinelLahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site Cl UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site Cl 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 (4[00) <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 ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill Cl 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/Rauch 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 -- ❑ I i - 60 — C1 > 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 l �;'s. ' — L_ _, ! fir_ Day Ph �j" e / ? Night Ph - - - <br />PROGRAM ELEMENT -� �;`,j FEE t(/ ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # 9 PERMIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ``i" ACCOUN-nNG OFFICE Date / <br />EH 0069 PINK FOR.M.doe I Rev. 07/07"99 <br />