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SAN JOAQUIN COUNT . Y ENVIRONMENTAL HEALTH DIVISION <br />%itAq'rt; PM >; PP( -nun TNFORNTAXION FORM (EH 00 69) <br />IffNew EH Program at Existing Facility ❑New EH Pro am and New Facility <br />Facility ID d d Program Record ID 1 <br />Facility Address I h () I' <br />(Please Check the appropriate description and specify site, number of units and perrinent information.) <br />fl—nAM 1600) <br />P 2nsa g ---3 -:5 <br />FOOD PR <br />F-1 Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs ❑ ua El <br />❑ Commissary C1 Dry storage only C3 with Food Preparation ❑Vending d iviachines —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 0 <br />❑ Mobile Food Prep 'Unit --Make Vehicle Type Color <br />Registration # License # Sticker # <br />El Temporary Food Facility ----Dates of operation from <br />to El Ice Plant <br />El Special Event - Dates of operation from to ❑Produce Stand <br />DAIRY PROGRAM (2000) <br />Grade A Dairy ❑ Grade B Dairy ❑ Milk Di eraser —N tuber of Containers in Multi -Head Unit <br />2-2 ( �7 V 4PP1� ��� / �ic� <br />CUPA ❑State Facility Surcharge (2399) � � �- <br />HAZARDOUS WASTE PROGRAM (2200) <br />{Hazardous Waste Generator -----------------------To Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Perrt-Lit-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 S forms <br />HOUSING PROGRAM (2400) <br />❑ Jail or Exempt Institution Number of Units <br />El Hotel/Nfotel ------ Number of Units <br />Employee housing (2 700) Use Employee Flousin, Labor Cann A licatiar; Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ i IPLISEP Cleanup Site ❑ UCC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />❑ <br />Cl Pool Spa El Out of Service Pool/Spa ❑Natural Bathing Area <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # License # Capacity _ <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets - <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag 1 Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ PracesslRecycle Facility <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd ---Number of Units <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Vehicle # _ <br />Number of Units <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ FarmlRancb Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />[I Primary Care C1 Acute Care ❑Skilled Nursing ❑Large Generator E] Small Generator ❑ Limited Hauler <br />❑ Common Storage Facility ❑ 2 - l0 --- ❑ 11 - 60 —11> 60 generators <br />1:1 Transfer Station El Veterinary Clinic d ty <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use P;VS EH0069 Blue r�Anficatian Form <br />EMERGENCY NOTIFICATION FORTHIs FACILITY AND/Oft PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGR,1m ELENIENT ?, M FEE <br />I,+SPECTOR# —7 PERMrr VALID <br />❑ Check k A.NIOU,NT PAID <br />❑ Cash. REvtTtivED BY <br />EH M69 PINI: FORM.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler�� <br />Date <br />ACCOLNrING OFFICE <br />INVOICE # <br />'pate <br />Rev. 07107/99 <br />