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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NL�.STERFILE RECORD LNFORNLMON FORM(EH 00 69) <br /> ew EH Program <br /> ❑ New EH Pro at Existing Facility <br /> and New Facility <br /> Facili ID 0 ! . -Y` Program Record ID �C SSI �g3 <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) 11 <br /> S Footage Food Handlers Course required: Yes❑ No <br /> 11 Restaurant: Seating Capaciy Square g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments C3 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 C1Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to C1Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade?.Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> H4zARDOUS WASTE PROGRANI(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generator------------------- <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) [I Conditionally Ru 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 /> El jail or Exempt Institution Number of Units <br /> (3 HoteUNlotel-------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 ❑ NPLUSEP Cleanup Site ❑ UIC Site <br /> C1 Water Quality Remediation Site <br /> ❑ Abandoned HW Site C1 non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) C3 Natural Bathing Area <br /> ❑ Pool ❑ Spa C1Out of Service PooUSpa <br /> Number of Pools/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(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> C3 Pumper Vehicle—Registration# <br /> License# p <br /> C3 Pumper Yard <br /> C1 Package Treatment Plant C1 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill <br /> C3 Transfer Station ❑ Ag/Cannery Waste Site C3roces [I CIA Landfill Site <br /> Ps/Recycle Facility <br /> C1 Waste Tire Facility C3Compost Facility ❑ Farm/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> C1 Primary Care C1 Acute Care C3 Common Storage Facility —❑ 2- 10 ❑ 11 -60—❑>60 generators <br /> ElTransfer Station ❑ Veterinary 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 Fel [IOther FEE <br /> PROGRAM ELEMENT ?/� FEE ❑ Food Handler�� <br /> PERMIT VALID to <br /> IySPECTOR# INVOICE# <br /> r�.vi0tt`1I PAID Date 3 <br /> ❑ Check# Date <br /> C3 Cash REVIEWED BY <br /> ACCouNrIIaG OFFICE Rev.07/07/99 <br />