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SAN JOAQUIN COUNTYENVIRONYIENTAL HEALTH MrSION <br />lASTERFH.E RECORD E 1FORINL4TION FORM (EH 00 691 <br />❑ New EH Prozrarn at <br />Facility Address `1DG/l t2Ch )2d <br />(Please Check the appropriate description and specify size. number of units and pertinent information.) _ <br />FOOD PROGRAM (1600) _ _. -c <br />ElRestaurant: Seating CapacitySquare Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines—Numbcr 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 B License g Sticker # <br />❑ Mobile Food Prep Unit—Make Vehicle Type - Color <br />Registration License u - Sticker X <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 />to <br />❑ Ice Plant <br />Produce Stand <br />❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility surcharge (2399) <br />FLAZA OUS 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 />❑ ABOVEGROUND 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 />❑ HoteliNlotel ----- —Number of Units ❑ Jail or Exempt Institution—Number of Units <br />Employee Housing (2700) Use Emalayee Nousin /LaAor Camp Aaolication Form - <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROLOOGO) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP 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 PooWSpas at Facility Cl Pool ❑ Spa ❑ Out of Service PaaVSpa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds ❑ 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 9 License p Capacity Vehicle ti <br />❑ Pumper Yard - ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400)- <br />❑ 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 ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler. <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112 - 10 --❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use P;YS E90069 Btue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM I Y' - <br />CONTACT PERSON 3 t --K-p Day Ph gfo.5-:tS�-G> <5 Night Ph �'.-3 L i % �:t <br />PROGRAMELEMENT FEE - c ❑Surcha 0 <br />_ INSPEROR i! 3_� 3 PERMIT VALID tel! tr) <br />r-1 Check AMO. PAID - -- <br />❑ Cash REvmvFm BY <br />EH 0069 PINK FORM.doc <br />ACCOUNMG OFFIOE .. - <br />