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` SAN JOAQUIN COUNTY ENVIROMAENTAL HEALTH DIVISION <br /> ML <br /> ASTERFELE RECORD L FORNLATION FORM(EH 00 69) <br /> ❑New EH Pro and New Facility <br /> ❑ New EH Program at Existing Facility tI <br /> Facili ID `� Proaram Record ID h IE T� <br /> Facility Address <br /> (Please Check the appropriate description and specify size.number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Square Footage Food Handlers Course required: Yes ❑ No <br /> El Restaurant: Searing Capacityq g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> 11 Retail Market----Square footage <br /> C1 with Meat Market only C3 Multiple Departments El Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle---Make License# Sticker# <br /> Registration# Color <br /> Vehicle Ty pe <br /> C1 Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to C1 ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to C1Produce Stand <br /> C3Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C1 iViilk Dispenser—Number of Containers in Multi-Head Unit <br /> 11 Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-------------------- ons Generated Per Year <br /> T <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) a Conditionally B Ru e HoustehoEd Hazardous Waste <br /> ❑ Permit-By-Rule Fixed Unit y- <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—i lumber of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ flotellivIotel-------Number of Units ication Form <br /> Employee Housing(2700) Use Emplozee HousinZ/Labor Came <br /> SITE MITIGATION(2900) UNDERGROUND <br /> GROUND INJECTION CONTROL(3000) <br /> 11 Environmental Assessment El UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ClUIC Site <br /> C1non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site C3 Water Quality Remediation Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> ClPool ❑ Spa C1Out of Service Pool/Spa <br /> Number ofPools/Spas at Facility , <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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle# <br /> [I pumper Vehicle—Registration# <br /> # <br /> C1 Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> C3 Waste Tire Facility C1 Compost Facility _ ❑ Farm/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units El Dumpsters>ZO cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1 Primary Care El Acute Care C1 Skilled Nursing C3 Large Generator C1 Small Generator ❑ Limited Hauler <br /> C1Common Storage Facility — <br /> ❑ 2- 10 ❑ 11 -60—❑>60 generators <br /> 11 Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH#069 Brue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> / 7 Day Ph � Night Ph <br /> CONTACT PERSON �yVC2 � V I <br /> ❑ Surcharge FEE _ [I other FEE <br /> PROGRAM ELEb ENT ZZ ( FEE to ❑ Food Handler�� <br /> Mff VALID <br /> INSPECTOR# ERINVOICE# ' <br /> A,NIOUNT PAID Datt <br /> e J <br /> ❑ Check# Date /5 <br /> ❑ Cash REVIEWED BY <br /> ACCOUNTING OFFICE Rev.07/07/99 <br />