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s SAN JOAQUIN COUNTY ENVIRON-IIENTAL HEALTH DIV i.SON <br /> NLASTERFILE RECORD Lit 1FORNLATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility New EH Program and New Facility <br /> Facility ID Program Record ID G' <br /> Facility Address I � S, � L Dbr/-) DD <br /> (Please Check the appropriate description and specify sib number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capaciry Square Footage Food Handlers Course required: Yes C3 No C1 <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 Tvpe Color <br /> Registration# License# Sticker# <br /> ❑ Ice Plant <br /> El Temporary Food Facility--Dates of operation from <br /> to <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> C1 Milk,./ ilk Dispenser—Number o�f7�ontainers in Multi-Head Unit <br /> C1 Grade A Dairy ❑ Grade B Dairy <br /> CUPA [IState Facility Surcharge(2399) l� APP i��'`�� P��U'�� \ Z l ` <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator---------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> C3 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 /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HoteUiviotel-------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 ❑ 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 /> ClC3 Pool Spa C1 out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) <br /> [1 Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) El Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License tt Capacity Vehicle# <br /> Cap <br /> C1 Pumper Vehicle—Registration# <br /> ❑ Pumper Yard El Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ A /Canoe Waste Site ❑ Sludge/Ash Site <br /> ❑ Transfer Station g Cannery <br /> ❑ Process/Rec cle Facility El CIA Landfill Site <br /> ❑ Waste Tire Facility [ICompost Facility y C1 Fann/Ranch Cleanup Site <br /> El Refuse Vehicles—Number of Units C1Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Large Generator ❑ Small Generator C3 Limited Hauler <br /> C1 Primary Care ❑ Acute Care C1 Skilled Nursing <br /> ❑ Common Storage Facility ❑ 2- 10--❑ I l -60—11 >60 generators <br /> C3 Transfer Station ❑ Veterinary Clinic b -- <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 /> PROGRA,vt ELEivIENT Z FEE C1Surcharge FEE C3 Other FEE <br /> INSPECTOR# 3 –7 PERMIT VALID to ❑ Food Handler—_� <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date e#,� () – <br /> Rev.07/07i99 <br /> EH 0069 PINK FORM.doc <br />