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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />VI ASTF.RFII.E RECORD hNFORNLaTION FORM (EH 00 69) <br />❑New EH Program at Existing Facility <br />❑New EH Program and New Fa <br />Facility ID 'C- -P"W _ Proaram Record ID VQ--() <br />Facility Address baa C. �►"�� <br />(Please Check the appropriate description and specify size, number of units and Perri nent information.) <br />FOOD PROGRAM (1600) <br />S Footage Food Handlers Course required: vEs C3 No El <br />1uare a Restaurant: Searing Capacity q g <br />C3 Commissary C1 Dry storage only C3 with Food Preparation ❑Vending Machines —Number of Units <br />iYlfootage C1with Meat Market only C1 Multiple Departments ❑ Prepackaged Goods Only <br />Li Retail arket ----Square <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />to <br />to <br />_ Color <br />Sticker"" _ <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Bilk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) Tons Generated Per Year <br />Hazardous Waste Generator ------------------- <br />Tiered Permitting Facility ❑Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />C1 Permrm <br />Permit -By -Rule Fixed Unit ❑ Permit -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 />❑ Jailor Exempt Institution Number of Units <br />❑ HoteUivlotel-------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 ElUST-CAPSite ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site [I UIC Site <br />❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) ❑ Natural Bathing Area <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooUSpa <br />VECTOR CONTROL PROGRAM (4000) ❑ Kennel <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Permanent Cosmetics (4122) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) Capacity Vehicle # <br />❑ Pumper Vehicle—Registration # License # P rY <br />❑ Pumper Yard <br />❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash Site <br />❑ Landfill ❑ A /Cannery Waste Site <br />❑ Transfer Station g <br />❑ Process/Recycle Facility (3 CIA Landfill Site <br />C1Waste Tire Facility ❑ Compost Facility ❑ FarmfRanch Cleanup Site <br />❑ Refuse Vehicles —Number of Units __ ❑ Dumpsters > 20 cu yd —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />C1Primary Care C1Acute Care ❑ Skilled Nursing ❑Large Generator ❑ ' - 1❑ small C3 <br />Generator ❑❑ >t60 genHr <br />rato s <br />11 Transfer Station C1 Veterinary Clinic <br />❑ Common Storage Facility — <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />rnnrr 4!"T DVD4Zl1N <br />PROGRAM ELCEENIENT FEE _ <br />INSFEC OP # `?3`� PERMIT VALID <br />❑ Check # <br />❑ Cash <br />A,rtOtr-IT PAID <br />Day Ph <br />IN Ph <br />❑ Surcharge FEE_ ❑ Other FEE <br />to <br />Date <br />❑ Food Handler�� <br />INVOICE # ' <br />Date <br />ACCOUNIING OFFICE <br />REVIEWED BY Rev. 07/07199 <br />