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SAN JOAQUIN COUNT- "ENVIRONMENTAL HEALTH DI ON <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69) <br /> New EH Program at Existing Facility ❑New EH ProRrarn and New Facility <br /> acility ID 1 Z 3 Program Record ID Q 7s�2 J <br /> Facility Address <br /> (Please Check the appropriate description and specify size number of units and nertinent inform tion.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YFs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number 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# License# Sticker# <br /> ❑ Mobile Food Prep Unit-.Make Vehicle Type Color <br /> Re;stration# 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—dumber of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> FL42_A�$OUS WASTE PROGRAM or--- U� � Z <br /> azardous Waste Generator-------------------Tons Generated Per Year <br /> Wert d Permitting Facility ❑ Condirionally 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 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 HoosinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ 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# License# Capacity Vehicle# <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 Landfdl 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 —❑ 2- to—❑ 11 -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 /> PROGRAMELEMENT "L7i FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �3 � PERMIT VALID to c ❑ Food Handler <br /> ❑ Check# AMOUNTPAm Date 9116lDg INVOICE# II�aD � <br /> 13 Cash REVIEWED BY ACCOUNTTNGOFFME Date 3�5ID <br /> EH 0069 PINK FORMAoc Rev.07/07/99 <br />