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a-- fikwk <br />SAN JTAQUIN COL -N'1 • VIRON-NIENTAL HEALTH DIV )N <br />NLASTERFLLE RECORD LNFORNLATIOiY FORA (EH 00 69) <br />New EH Program at Existing Facility_ ❑New EH Program and New Facility <br />Facility ID FA nr) ms 9 5 Program Record ID 7Y <br />Facility Address j1 �33 N�eWtDOL ROGZA stDGIGf� <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />Z Commissary C1 Dry storage only C3 with Food Prepararion ❑Vending Machines —Number of Units <br />❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ :Mobile Food Vehicle ---Make <br />Registration R <br />Cl iVtobile Food Prep Unit --Make <br />Registration T <br />❑ Temporary Food Facility --Dates of operation <br />❑ Special Event - Dates of operarion from <br />DAIRY PROGRAM (2000) <br />Vehicle Type <br />License T <br />Vehicle Type <br />License R <br />from to <br />to <br />Color <br />Sticker <br />_ Color <br />Sticker u <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />l-LAZARDOUS 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 />,2ABOVEGROUND 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-------Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee Housing/Labor Camp Avolicatiort Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 11 Spa C1 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 />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />WQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration T _ <br />❑ Pumper Yard <br />License K <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle R <br />❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C3 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 11 Acute Care ❑ Skilled Nursing C3La Large Generator C3 Small Generator 11 Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - IO ❑ 1 l - 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 />PROGRAM ELEMENT 2 _T' I v FEE <br />INSPECTOR 'r <br />❑ Check <br />PERMIT VALID <br />AINIOUNT PAID <br />❑ Cash REVTE<</ED BY <br />EH 0069 PNK FOR.'t.doc <br />Day Ph <br />❑ Surcharge FEE <br />to <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />Date LNVOICE n <br />ACCOUNTING OFFICE -j j Date / <br />Rev. 07"07i99 <br />