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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MI ASTERFILE RECORD U 1FORMADON FORM(EH 00 69) <br /> ❑New EH Program <br /> ❑ New EH Program at ExistingFaeilitY <br /> and New Facility <br /> Facility ID 'FD, Proaram Record ED <br /> Facility Address atm �• SPEP-�. t7 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: YEs❑ No ❑ <br /> C3 Restaurant: a Restaurant: Seating Capacity - q g ❑Vendin Machines—Number of Units <br /> C3 Commissary ❑ Dry storage only ❑ with Food Preparation . g <br /> C3 Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type _ Color <br /> C3 Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> C3Temporary Food Facility--Dates of operation from to 13Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> H42aRD6US WASTE PROGRAivt(2200) _ Tons Generated Per Year L <br /> Hazardous Waste Generator-------------- --- ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Permit-By-Rule Rule Household Hazardous Waste <br /> ❑Permit-By-Rule Fixed Unit y- <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAbt(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ HoteUMotel-------Number of Units <br /> Employee Housing(2700)Use Employee Nousine/Lahor in Applicatiaz Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTIROL(3000) <br /> ON CONT <br /> UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Environmental Assessment ❑ L/S it Cleanup Site ❑ RWQCB Cleanup Site [:1 Water Quality Remediation Site <br /> ❑ Abandoned HW Site ❑ UST-CAP <br /> RECREATIONAL HEALTH PROGRAM(3600) [] out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa <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 /> 11 Tattooing(4121) ❑ Body Piercing(41 2U) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle <br /> ❑ Pumper Vehicle—Registration# License# P ty <br /> C1Pumper-Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ SludgetAsh Site <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site [3 CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ FarmfRanch Cleanup Site <br /> ❑ Refuse Vehicles—;`lumber of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> p' ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator [] 11 -60---❑>60 Senecators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility—❑ 2-10 <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0469 Blue Anolication Form <br /> EMERGENCY NOTIFICA710N FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> FEE ❑Surcharge FEE [I Other FEE <br /> PROGRA,Nt ELEMENT - ❑ Food Handler�- <br /> PERMIT VALID to <br /> IYSPECTOR# J jNVOICE# - <br /> ❑Check# AMOUNT PAID Date <br /> ACCOUNTNG Ot�ICE Date <br /> 0 Cash REvMVED BY Rev.07/07"99 <br />