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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> ML ASTERFLLE RECORD LNFORNLkTION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Pro and New Facility <br /> FacilityID Program Record ID e�La.5gi <br /> Facility Address <br /> (Please Check the appropriate description and specifysi_ze•number of units and pertinent information.) <br /> F000 PROGRAM(1600) <br /> C3 Restaurant: Searing CapacitySquare Footage <br /> Food Handlers Course re aired: Yes El No El <br /> ❑Vending Machines—Number of Units <br /> ❑ Commissary El Dry storage only ❑ with Food Preparation b <br /> ❑ Retail'Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Calor T <br /> Type❑ 'tobile Food Vehicle---Make VehicleSticker n <br /> Registration R License# <br /> Vehicle Type Color <br /> 13 Mobile Food Prep Unit--Make Sticker# <br /> Registration# License# <br /> to El Ice Plant <br /> ❑ Temporary Food Facility----Dates of operation from 11 Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ 'Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C3 Grade A Dairy ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) - � <br /> fLAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator ------------------ —Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST <br /> UNDERGROUND STORAGE THINK(UST) PROGR4'M(2300) Use UST A and B orms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or <br /> E] HoteU'Iotel-------Number of Units Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee f1'ausiD Lahar Cam2 Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site C1 NPL/SEP Cleanup Site ❑ UIC Site <br /> SEP Cleanup Site C1RWQCB Cleanup Site C3 Water Quality Remediation Site <br /> ❑ Abandoned HW Site ❑ non-NPLI <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ NaturaE Bathing Area <br /> Number of PoolslSpas at Facility El Pool El spa <br /> C1 Out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> � <br /> F-1 Body Piercing(4120) ❑ permanent Cosmetics(4122) <br /> [I Tattooing(412 1) <br /> LIQUI ) WASTE PROGRAM(4200) Vehicle <br /> R #� <br /> ❑ Pumper Vehicle—Registration <br /> License# Capacity <br /> E] Pumper Yard El Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C3 Transfer❑ Landfill Station g❑ A I Cannery Waste Site O❑ Pracess/Recycle Facility C1 CIA Landfill Site <br /> C1Waste Tire Facility C1Compost Facility C1 Farut/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care C1 Skilled Nursing El Large Generator [I small Generator ❑ Hauler <br /> Limited Hou <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—— <br /> ❑ f l -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Bfue A licatiOn Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ❑ Surcbarge FEE ❑ Other FEE <br /> PROGRAM ELENIFNT 2� FEE [I Food Handler_____--, <br /> 1,-4SPECT0R# PTcFtMrr VALID t0 <br /> Date INVOICE# <br /> E-] Chcck# AINIOU`1T PAID L� 3 D(a <br /> AccouNTING OFFICE Date <br /> ❑ Cash REVtEwED BY }Zev.07107;99 <br />