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SAN JOAQUIN <br />ML ASTE <br />❑ New EH Program at Exis <br />Facility ID 00 ). /n t: <br />RECORD INFORNLATION <br />HEALTH <br />and New Fa-( <br />)3 )G'7 <br />Facility Address S 10 N (r1ra."T JT VS <br />(Please Check the appropriate description and specify size number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing CapacitySquare Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market--Squaze footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation <br />❑ Special Event - Dates of operation from— <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399 <br />K42A SOUS WASTE PROGR,>,i 0 <br />JiR'Hazardous Waste Genera(22------------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 USTA and forms <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />Food Handlers Course required: YEs ❑ No ❑ <br />❑Vending Machines —Number of Units - <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />_ Color <br />Tricker # <br />_ Color <br />Sticker # <br />from to ❑ Ice Plant <br />to ❑ Produce Stand <br />❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />HOUSING PROGRAM (2400) <br />❑ Hotet/Motel------- Number of Units ❑ Jail or Exempt Institution—Number of Units <br />Employee Housing (2 700) Use Employee [TousinglLahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local MV 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 PooWSpas at Facility ❑ Pool ❑ Spa Cl Out of Service PooVSpa ❑ Natuml Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm—Maximum number of birds <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <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 11 Urge Generator ❑ Small Generator ❑ Limited Hauler. <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112 - 10 — ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />CONTACTPERSON <br />PROGRAM ELEMENT2 Z V O FEE _ <br />INSPECPDR#$S73 PERMRVALID <br />❑ Check # AMOUNT PAID _ <br />❑ Cash REVIEWED BY <br />EH 0069 PINK FORM.doc <br />Day Ph <br />Night Ph <br />❑ Surcharge -FEE ❑ Other FEE —. <br />to ❑ Food Handler_ <br />Date % /r0V INVOICE# ' <br />ACCOUNONG OM�E <br />Date <br />Rev. 07107"99 <br />