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SAN JOAQUIN COUNTY ENVIRONMENTAL-HEALTH DIVISION <br /> Mi ASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ED <br /> Facility Address <br /> (Please Check the appropriate description and specify size'number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YES❑ No ❑ <br /> C3 Commissary C3 Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Meat Market only C1 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 /> ❑ <br /> to ice Plan*, <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> CTHazardous Waste Generator------------b-----Tons Generated Per Year C � <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,4 2nd-B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700)Use Employee HourinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1 UST-CAP Site ❑ Local HNV Cleanup Site 13NPL/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 /> ❑ <br /> 13 Pool <br /> Spa [I Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel « <br /> ❑ Poultry Farm Maximum number of birds <br /> TATT)Oj BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> El Pumper Vehicle—Registration# License# Capacity <br /> C1 Pumper Yard ❑ Package Treatment Plant 13 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> 11 Landfill C1 Transfer Station ❑Ag/Cannery Waste Site g <br /> ❑ Process/Rec cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y ❑ Farm/Ranch Cleanup Site <br /> C1 Refuse Vehicles—Number of Units ElDumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> C1 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—112- 10--❑ it -60—060 <br /> rs <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSE110069 Blue Ayplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> t Day Ph 157�16LX> Night Ph f Z--5-ZOO 04A- <br /> CONTACT PERSON <br /> PROGRAIIA ELEMENT 2Z-Z O FEE ❑Surcharge FEE ❑ Other FEE <br /> I,ISPECTOR# Cf Q93 PERMIT VALID L °3 to a 1 aa— ❑Food Handler_____—, <br /> ❑ Check# A�rIOUNT PAID Date INVOICE# ` <br /> ❑Cash REvIBveD BY ACCOtrxrlNG ONCE Date o B� <br /> Rev.07/07i99 <br /> .....nen orgy <br />