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SAN JOAQUIN COUNTY ENVIRONMENTAI,HEALTH DIVISION <br /> NL-kSTERFILE RECORD L 1FORItiLATION FORM(EH 00 69) <br /> ❑ New EH Pro am at Existing Facility <br /> ❑New EH Progam and New Facility <br /> Facili ID �0 b0 b Program Record ED ') S� S/S <br /> c � <br /> Facility Address 2 �� <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 C3 No 11 <br /> C1 Restaurant:Restaurant: Seating Capacity q g ❑Vending Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br /> El with <br /> C1 Retail Market----Square footage h Meat Market only C1 Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ iVlobile Food Vehicle---Make License K Sticker# <br /> Registration R Color <br /> Vehicle Type <br /> El Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000 <br /> C1Grade B Dairy El Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAiNI(2200) <br /> --Tons Generated Per Year <br /> ❑ Hazardous Waste Generator------------------' (CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized it ❑ Permit-B C1 Conditionally Exempt(Rule Household Hazardous Waste <br /> C1 Permit-By-Rule Fixed Unit Y- <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAiVI(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HoteUMotel-------Number of Units �— <br /> ahor Came Application Form <br /> Employee Housing(2700) Use Employee Hou.sinz/L <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Site [I UIC Site <br /> Cleanup <br /> C1 Environmental Assessment UST-CAP EP Cleanup Site � <br /> te Cleanup ❑RWQCB Cleanup Site PL/S❑ Water Quality Remediation Site <br /> ❑ Abandoned HW Site C1non-NPL/S P ❑ <br /> RECREATIONAL HEALTH PROGRAM(3600) C3 out of Service Pool/Spa [1Natural 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 M P eP O RAM(4100) C3 Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle#� <br /> C1 Pumper Vehicle—Registration R <br /> � P �' <br /> ❑ Pumper Yard <br /> C3 Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C1 Transfer Station <br /> C3 Ag/Cannery Waste Site El CIA Landfill Site <br /> C1 Landfill <br /> ❑ Process/Recycle Facility nch Cleanup Site <br /> C1 Waste Tire Facility ❑ Compost Facility ❑ Farm/Ra <br /> C3 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 11 Acute Care ❑ Skilled Nursing C3 Large Generator ❑ � 10 60 <br /> Small❑Generator 0 Q Limited generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility — - <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 /> FEF, ❑ Surcharge FEE ❑ Other FEE <br /> rPROGRAiNt ELEMENT ' — to L 3 1 c, ❑ Food Handler <br /> ECTOR# � PERMIT VALIDDateINVOICE#heck# ANtOUNTPAID Date 5 �� 'Cash REVIE%VED BY <br /> ACCOUNTING OFFICE Rev.07/07/99 <br />