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` SAN JOAQUIN CO I TY ENVIRONMENTAL HEALTH DIVISION <br /> MASTE E RECORD I11F0R[NLkTI0N FO 1(EH 00 69) <br /> ❑ New EH Program at Existing acility <br /> New EH Program and New Facility <br /> Facili ID S ( O 9 rogram Record ID o-5 S a <br /> Facility Address <br /> (Please Check the appropriate des ription and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: YEs❑ No 11 <br /> C1 Searing Capac ry Square ga <br /> F1 Commissary C1 Dry storag only C1 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square foot ge ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle--Mak Sticker# <br /> Registration License#Vehicle Color <br /> hicle Type <br /> C1 Mobile Food Prep Unit--Mak License# Sticker# <br /> Registration ❑ Ice Plant <br /> to <br /> ❑ Temporary Food Facility— Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of ope tion from <br /> to <br /> DAIRY PROGRAM (2000) <br /> C3 ivtilk Dispenser—Number of Containers in Mufti-Head Unit <br /> ❑ Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surch rue(2399) <br /> HAZARDOUS WASTE PR GRAiM(2200) <br /> C1 Hazardous Waste Generator------------------Tons Generated Per Year <br /> Tiered Permitting F cility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STO GE TANK FACILITY(AST)('_390)—Number of AST <br /> UNDERGROUND STORA E TAINK(UST)PROGRAM(2300)Use UST,4 and B forms <br /> HOUSING PROGRAM(2400) <br /> C1Jail or Exempt Institution Number of Units <br /> ❑ Hotel/'Motel-------Number of nits <br /> Employee Housing(2700) Use Em to re Hou.rinv/Lahor Cam rl licatian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> EP Cleanup Site ❑ RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> C1 Abandoned HW Site ❑ non-NPL/S <br /> RECREATIONAL HEALTH PR GRAM(3600) ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility El Pool Cl spa <br /> C1 out of Service Pool/Spa <br /> VECTOR CONTROL PROGRA (4000) ❑ Kennel <br /> ❑ Poultry Farm Maximu number of birds <br /> TATTOO BODY PIERCING ERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4 00) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registratio # License# P �' <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> C] Pumper Yard <br /> SOLID WASTE PROGRAM(44 0) 1 ❑ Sludge/Ash Site <br /> El Landfill C1ransfer Station [I Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility <br /> [I CIA Landfill Site <br /> ❑ Waste Tire Facility C1ompost Facility C3Farm/Ranch Cleanup Site <br /> C1 Refuse Vehicles—Number of nits C1 Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM 4500) <br /> ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> C3 Primary Care ❑ Acut Care ❑ Skilled Nursing <br /> ❑ Common Storaue Facility — <br /> ❑ 2_ 1p ❑ 11 -60—❑>60 generators <br /> ❑ Transfer Station ❑ Vete nary Clinic <br /> PUBLIC WATER SYSTEM PR GRAM(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 /> FEE ❑Surcharge FEE [I Other FEE <br /> PROGRAM ELEMENT [I Food Handler <br /> PERMIT VALID to <br /> IVSPECTDR# jIJVOICE# ` <br /> ❑ Check# tifOLNT PAID Date _ <br /> ACCout TING OMCE �jL Date 5 <br /> El Cash REVIEWED BY Rev.07/07/99 <br />