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• SAN JOAQUIN COUN NVIRON1MENTAL HEALTH DIVTWON <br /> ML ASTERFME RECORD LNFOR?iLATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH progrant and New Facility <br /> Facility ID 5-71 z- Program Record ID <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 CapacitySquare Footage Food Handlers Course required: YFs❑ NO C] <br /> 1Commissary ❑ Dry stooge only ❑ with Food Preparation ❑Vending iYlachines—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 R Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type - Color <br /> Registration# License R 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 PROGRA X00) <br /> ❑ Hazardous Waste Gene for--- -----------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pettnit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number OFAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms - <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotellivlotel-------Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Houslne/Lahor Cama Application Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <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 Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - -- <br /> ❑ Pumper Vehicle—Regisrradon9 License# Capacity Vehicle# <br /> ❑ Pumper Yard - ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) - - - - - - --- - - - - - <br /> ❑ Landfill ❑Transfer Station ❑Ag/Caooery Waste Site ❑ SludgelAsh 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 ❑ F2rmIR2nCh 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 Stonge Facility—112-IO—❑ 11-60—❑>60 generators - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue ApplicadOtr Form _ <br /> EMERGENCY NOTIFICATION FOR THIS FACT TY AND/OR P OGRAM <br /> eO.r oyrrWA <br /> CONTACT PERSON 'ti*" 10-� ay Ph Night Ph <br /> PROGRAM ELEMENT Z Z `U FEESurcharg4E -❑ Other FEE - <br /> INSPEcrolt# '7 PERMIT VALID r7 D /b4 to (7�3 j �. ❑Food Handler " <br /> ❑Check# AMOUNT PAID I L I,� - Date _ INVOICE ff <br /> ❑ Cash REvm%vEDBr AccourfmGOFFtcE y Date . l <br /> EH0069 PINK FORM.doc - - - Rev.0710769 <br />