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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV N.SON <br /> NLASTERFILE RECORD LNFOR:NL-kTION FORM(EH 00 69) <br /> `ew EH Program at Existing Facility 0New EH Pro am and New Facility <br /> Facility ID CA S Program Record ED <br /> Facility Address <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 /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail ivlarket----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle----, take Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration" 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 ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAvI(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 ❑ Perm;;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-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment [IUST-CAPSite C1W Local HCleanup Site ❑ NPL/SEP Cleanup Site C1 UII�Site <br /> Cl .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 /> [I Poultry Farm Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) 11 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 /> 13 Landfill Waste Site ❑ Sludge/Ash Site <br /> ❑ Transfer Station C1 Ag/Cannery b <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 C1 Acute Care ❑ Skilled Nursing C1La be Generator C1 Small Generator 11 Limited Hauler <br /> Cl Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2- 10--❑ I 1 -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 Day Ph Night Ph <br /> PROGRAM <br /> M ELEENT 2��1 FEE C3Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# Amou:r-r PAID Date INVOICE ur <br /> ❑ Cash REvtEWED BY (p 0 I ACCOUNTING,OFFICE Date <br /> Rev.07/07;99 ' <br /> EH 0,069 PCNK FOR.M.doc VU <br />