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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NLASTERF .E RECORD ]I1FORNLaTION FORv1(EH 00 69) <br /> II <br /> E�New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ID 2 0,1 / (J <br /> Facility Address \\100 -:—NRS� � '�'��- , cp` <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C3 Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YES 13 No 11 <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 /> C3 Temporary Food Facility-----Dates of operation from to C3 Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy Cl Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> E Hazardous Waste Generator-----------------------Tons Generated Per Year T �7 <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 /> C1Hotel/Motel-------dumber of Units 11 Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site Cl 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 Faciliry Cl Pool C1 Spa 11 Out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [I Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> F-1Tattooing(412 1) El Body Piercing(4120) C3 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration# License# CapacityVehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C3 Transfer Station C3 Ag/Cannery Waste Site 11 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 /> 11 Primary Care C3 Acute Care C3 Skilled Nursing C3 Large Generator C3 Small Generator ❑ Limited Hauler <br /> C3Transfer Station ❑ Veterinary Clinic 13Common Storage Facility -0 2- 10--❑ 11 -60—13>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 /> PROGRAM ELEMENT a FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �cL�� PERMIT VALID N ]�'� to =b-% ❑ Food Handler <br /> ❑ Check# AmoUr'r PMD Date INVOICE# <br /> C3Ot1 Cash REVIEWED BY ACCmNG OFFICE �:� Date Z%l <br /> - Rev.07/07/99 <br /> EH 0069 PINK FOR.M.doc <br />