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SAN JOAQUIN COUNTY ENVIRONNIENTAL:HEALTH DIVISION <br /> ?YL.-kSTERFTLE RECORD L 1FORttiLATION FO 1(EH 00 69) <br /> New EH Pro and New Facility <br /> ❑ New E Pro m at Existing Facility <br /> Faciii ID G U (�1 In S Program Record ID <br /> Facility Address 3"� � <br /> ��S) \-A :-c n, <br /> ent information.) <br /> (Please Check the appropriate description and specify size•numbe_ r_ of units and pertin <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yrs C1 No 11❑ Restaurant: Searing Capacity Square Footage <br /> ❑ Commissary C1 Dry storage only <br /> ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> C1 Retail Market--Square footage <br /> C3 with Meat Market only C1 Multiple Departments C1 Prepackaged Goods Only <br /> Color <br /> Vehicle Type Sticker# <br /> ❑ Mobile Food Vehicle--Make License# <br /> Registration# Color <br /> Vehicle Type Sticker <br /> ❑ ivlobile Food Prep Unit--Make License# ❑ Ice Plant <br /> Registration# to <br /> C1 Produce Stand <br /> C1 Temporary Food Facility--Dates of operation from to <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> RAZARDOUS WASTE PROGRAM(2200) --Tons Generated Per Year <br /> C3 Hazardous Waste Generator------- -- ❑ Conditionally Exempt t(CE) <br /> Tiered Permitting Facilitv ❑ Conditionally Authorized(CA) ❑ pertrtit-By-Rule Household Hazardous Waste <br /> ❑ permit-By-Rule Fixed Unit <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--'lumber of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGR.a.ivi(2300)Use <br /> rrcT.f and fi forms <br /> HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution Number of Units <br /> ❑ Flotel/ivlotel------Number of Units <br /> H .siI <br /> �/LahorCaml /,cQtioR Form <br /> Employee Housing(2700) Use Employee <br /> UNDERGROUND INJECTION CONTROL(3000) ❑ UIC site <br /> SITE MITIGATION(2900) eanu 11NPL/SEP Cleanup Site <br /> UST-CAP Site CB Cleanup Site Water Quality Remediation Site <br /> C1 Environmental Assessment anon-NPIJSEP Cleanup Site � <br /> te ❑CC1RWQ p Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Poovspa <br /> E] Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> C3 Pool <br /> 11 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# <br /> Capacity Vehicle# <br /> C1 pumper Vehicle—Registration# ve Treatment Plant C3 Chem <br /> Toilets Number of Units <br /> C1 Pumper Yard ❑ Packa, <br /> 1 Waste Site ❑ SludgelAsh Site <br /> SOLID WASTE PROGRAM(4400) ❑ Ag/Cannery ❑ CIA Landfill Site <br /> ❑ Landfill ❑Transfer Station <br /> ❑ Compost Facility ❑ Process/Recycle Facility ❑ Farm[Ranch Cleanup site <br /> ❑ Waste Tire Facility P <br /> _ <br /> ❑ Dumpsters>20 cu yd—Number of Units <br /> C3 Refuse Vehicles—dumber of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Large Generator ❑ Small Generator [I Limited Hauler <br /> d Nursing � ene11 ❑>60 generators <br /> C3 Primary <br /> Skilled Primary Care ❑ Acute Care ae Facility 2- ❑ -60 <br /> — <br /> El Transfer Station ❑ Veterinary Clinic <br /> El Common Stora, <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 B1ueAyyatior:Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM Ph <br /> Day Ph <br /> CONTACT PERSON [3Other FEE <br /> ❑Surcharge FEE <br /> PROGRA�1 ELENIENT o ' FEE to [3Food Handler <br /> I,ySPECTOR# �A PERMITVALID INVOICE# <br /> Date � / <br /> C1 Check# A�rIOU`1T PAID - Date `J <br /> ACCOuNMG OFFICE Rev.071071,99 <br /> ❑ Cash REYIE1vED BY <br />