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SAN JOAQUIN COUN', � ENVIRONMENTAL HEALTH D SION <br /> NLaSTERFTLE RECORD INFORNLATION FORNI(EH 00 69) <br /> New EH Program at Existing Faciliry ❑New EH Program and New Facility <br /> Facility ID 0 of-, Program Record ED <br /> Facility Address \Nv;(r, <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YEs❑ 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 /> Registration# - License;; Sticker# <br /> ❑ Temporary Food Facility--Dates of operarion 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 /> HAZARpOUS WASTE PROGRAM(2200) L 6j-7.(�N-�, - <br /> CTHazardous 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 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 E ploree HousinelLahor 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 C3 Pool ❑ Spa Cl Out of Service Pool/spa [I Natural Bathing Area <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(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> C3 Pumper Vehicle—Registration# <br /> License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud elAsh Site <br /> ❑ Landfill C1 Transfer Station C3 Ag/Cannery Waste Site g <br /> /Rle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Vehicles <br /> -N ❑ Compost Facility ❑ Processecyc <br /> ❑ Refuse Vehiccles—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 /> Cl Transfer Station ❑ Veterinary Clinic C1Common Storage Facility -0 2- 10--C311 -60—0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PiYS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELENIENT Zy FEE� ❑ Surcharge FEE (3 other FEE <br /> I PERMIT VALID�— to ❑ Food Handler — <br /> INSPECTOR# ^� <br /> INVOICE# ' <br /> C1Check# AmouNr PAID �— Date <br /> AC <br /> El Cash REVIEWED BY COUNTING OFFICE Date Rev.07/07/99 <br /> EH 0069 PINK FOR,II.doc <br />