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10 <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> N ASTERFILE RECORD>,IFORNNATION FORNI(EH 00 69) <br /> ❑ New EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> Facility ID y Program Record ID a <br /> Le <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: Yes C1 No El <br /> El Searing Capacity Square g ❑Vendino Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make License,"r Sticker# <br /> Registration n Color <br /> Vehicle TyColor <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration to C1Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to 11Produce Stand <br /> ElSpecial Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> F-1 Grade?.Dairy C1 Grade B Dairy <br /> CUPA C1 State Facility Surcharge(2399) ' <br /> RAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generator--------------------- <br /> Tiered Permitting Facility ❑ Conditionally Authorized it 0 Conditionally <br /> est B a1Ru e 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)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt institution Number of Units <br /> C1 IioteUivlotel-------Number of Units <br /> Emptoyee Housing(2 100) Use Employee Nousrn�/Labor Camp!I pplicafion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 0 UIC Site <br /> C3 Environmental Assessment C1 UST-CAP Site ❑ Local HW Cleanup Site LJNPL/SEP Cleanup Site <br /> ❑ Abandoned HSV Site ❑ non-NPL/SEP Cleanup Site [I RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) (] put of Service PooUSpa El Natural Bathing Area <br /> Number of pools/Spasat Facility ❑ Pool C] 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 /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle# <br /> C1 Pumper Vehicle—Registration k <br /> # p �' <br /> ❑ Package Treatment Plant El Chemical Toilets Number of Units <br /> C1 Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill C3 Transfer Station C3 Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> C1Waste Tire Facility C3Compost Facility C3Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ted <br /> ❑ Primary Care C1 Acute Care C1 Skilled Nursing <br /> [I Common Storage Facility _E1 2- 10❑ Large Generator C3 Small C1 <br /> Generator ❑>160rgeneraato�r <br /> ElTransfer Station C1Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> ❑ Surcharge FEE ❑ Other FEE <br /> PROGRAim ELEMENT FEE ❑ Food Handler f <br /> PERMIT VALID to <br /> I;vseecrolz# jNVO[CE# <br /> ❑ Check# AbfOUNT PAID Date <br /> -19.117 <br /> Date <br /> ❑ Cash REVIEWED BY ACCOuNrtNG OFFICE Rev.07/07i99 <br />