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SAN JOAQUIN COUNTY .4VIRONMENTAL HEALTLI DIVY �)N <br /> NLASTERFIELE RECORD INFORNIATION FORM(EH 00 69) <br /> K ew EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili ID Program Record ED <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number. f units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goads Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility---Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> FLAZZARXIUS 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 TANK(UST) PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility C1 Pool C1 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm Maximum number of birds [1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard C1 Package Treatment Plant C1 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site El Sludge/Ash Site <br /> ❑ Process/Rec cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility C1 Compost Facility y <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ '-- 10---❑ I I -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 B/ueApplieation Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAm ELEiV1ENTL ` FEE C1Surcharge FEE ❑ Other FEE <br /> [vseecroR# `� r� PERMIT VALID ° ; z- to L ( c r ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE ' Date <br /> Rev.07/07199 <br /> EH 0069 PINK FORLt.doc <br />