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SAN JOAQUIN COU TY Ei - ROti'1LENT:kL HEALTH DItiZSI- <br />tiLaSTERFILE RECORu 0-FOR-NLA.TIOL FORM (EH 00 69) <br />\'ew, EH Program at Existing Facility ❑ lew EH Pro and New Facility <br />ID <br />Facility 7 Program Record ED /� <br />Facility Address oZ E W ()A— <br />(Please Check the appropriate description and specify sizes number of units and Pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ :Mobile Food Vehicle ---Make Vehicle Type Color <br />Registration P License # Sticker R <br />Cl Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration T License # Sticker <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant <br />❑ Special Event - Dates of operation from to ❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy Cl Grade B Dairy ❑ ylilk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA []State Facility Surcbarge (2399) <br />HAZARDOUS WASTE PROGRA,NI (2200) <br />❑ Hazardous Waste Generator------------------Toas 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 />Q'kBOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST_ <br />UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/i<Iotel-----Number of Units Cl Jail or Exempt Institution Number of Units <br />Employer Housing (2700) Use Emplovee HousinglLahor Camp Acylicarion 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 C3 Spa C3 Out of Service PooUSpa C1 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ 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 T License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ,lumber of Units <br />SOLID WASTE PROGRAM (=4400) <br />❑ Landfill C] Transfer Bladon ❑ Ay / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility C1 Compost Facility ❑ Process/Recycle Facility C1CiA 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 ❑ I 1 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PK�S EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRA.m ELEXE`iT � FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR# PE %Irr VALID to ❑ Food Handler�� <br />❑ Check # A.Y[On, -r PAm Date INVOICE T <br />C3 Cash RFvIEweD 8Y 6 ACCOU`rriNG OFFICE J Date -3/GI !' <br />Rev. OV07i99 <br />EH M69 PINI: FOR.M.doc <br />