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SAN JOAQUIN C UNITY ENVIRON11t1ENTAL HEALTH DIVISION <br /> NL4STE E RECORD IYi FORiNLATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing aeility ❑New EH Program and New FsciIity <br /> Facilityn <br /> ID /,zo Progratn Record ID Y'�0 5/1,, <br /> Facility Address <br /> (Please Check the appropIti <br /> cription and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(160 - <br /> ❑ Restaurant: Seatiniry Square Footage Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Commissary ❑ Da only ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market—Sqage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehiclee Vehicle Type Color <br /> Regf License R Sticker <br /> ❑ Mobile Food Prep Ue Vehicle Type Color <br /> RegR License R Sticker <br /> ❑ Temporary Food FaDates of operarionfrom to ❑ Ice Plant <br /> ❑ Special Event - Dates of op ration from to C1 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> C1 Grade A Dairy C1 Grade B Dairy C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surc arge(2399) - "? 2 2• d <br /> fLaZARDOUS WASTE P OGRA�vt(2200) -C,_ VS�(3 Cj I l <br /> 0 Hazardous Wast Generator--------- --Tons Generated Per Year <br /> Tiered Permitting acility C1 Conditionally Authorized(CA) <br /> C1 Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pem-Lit-By-Rule Household Hazardous Waste <br /> ❑ ?ABOVEGROUND ST RAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STOR. GE TANK(UST)PROGR_- M(2300)Use UST A and B(orms <br /> HOUSING PROGRAM(2400) <br /> Cl HoteVitifotel---Numbtr o Units C1 Jail or Exempt Institution Number of Units <br /> Employee Housing(2 i00)Use E (o ee Hou.rinzlLabor Cam Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HNV Cleanup Site ❑ NPUSEP Cleanup Site ❑ UTC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH P 10GRAM(3600) <br /> Number of Pools/Spasat Facili C3 Pool ❑ Spa C1 Out of Service PooVSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROG M 44 00) ❑ Kennel <br /> ❑ Poultry Farm Maxim m 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.( 200) Ca i Vehicle#�_ <br /> ❑ Pumper Vehicle—Registrati n 9 License R Pacry <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM( 00) ❑ Sludge/Ash dAsh Site <br /> C1 Landfill ❑Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Re cle Facility [I CIA Landfill Site <br /> C1 Waste Tire Facility [I Compost Facility � c}' - C1Fsrm/Rsnch Cleanup Stte <br /> C1 Refuse Vehicles—Number o Units ❑ Dumpsters>_0 cu yd—Number of Units <br /> MEDICAL WASTE PROGRA (4500) <br /> g 11 Large Generator ❑ Small Generator 11 ;Limited Hda[ter, <br /> C1 Primary Care C1 Acu a Care C1 Skilled Nursin <br /> C1 Transfer Station ❑ Vet rinary Clinic <br /> [I Common Storage Facility—❑ 2- 10 ❑ it-60—❑ 60 g <br /> PUBLIC WATER SYSTEM P OGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph — Night Ph <br /> PROGRAA1ELEhiENT Zc�- FEE g N d ❑Burch rg E ❑ OtherFEE <br /> I,tSPECToIt>* ( PERMIT VALID to -t 3j ❑Food HSndler_ <br /> ❑ Check K ti10U;jT PAID ' Date - INVOICE#. <br /> [I Cash RvED s AccourrratG OFFICE Date - <br /> . _ Rrr 07f07e99 <br />