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i SAN JOAQUIN COUN i i _.NVIRONIIENTAL f[EALTH DI`'.,,�-=ON � NL-kSTr"RFILE RE:ORD I]NFORtiLkTION FORNI(EH 00 69) ❑ New EH Pro am at Existing Facilitv ❑New EH Program and New Facility Facili ID Program Record ED Facility Address �) V (Please Check the appropriate description and specify 4e, number of units 4d 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# ❑ 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 ❑ Pet-B Rule Household Hazardous Waste -ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST. UN .; DERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ HoteUMotel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee Housim,lLahor 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 Remediatioa Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -112- 10--❑ 11 -60—❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PfVS EH0069 Blue Application Form , I EmERGENC4 NOTIFI ATION FOR THIS FACILITY AN ort PROGRAM CONTACT PERSON / 11 l�/Z? Day Ph n 0� Night Ph PROGRAim ELEME /TG FEE 11Surcharge FEE ❑ Other FEE INSPECTOR# C / l PERN11r VALID to ❑ Food Handler ❑ Check# ALIO I PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date .00 EH 0069 PINK FOR,It.doc Rev.07/07/99