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SAN JOAQUIN COCNI7 ENVIRONNTENTAL HEALTH DIb,-4sION NLASTERFTLE RECORD LNFORVLATION FORVI(EH 00 69) New EH Program at Existing Facility ❑New EH Pro nd New Facility �O Facility IDffy5y,&J�" r ram Record ID Facility Address I I Ai (Please Check the approortate description and specify side number of units and oerrinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operndon from to — 11 Ice Plant C3Special Event - Dares of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit GUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Perini t-By-Ru le Household Hazardous Waste 0.BOVEGROUND STORAGE TANK FACILITY(ASI)(2390)--Number of AST �_ 1- 2,000 d(�.� UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ HoteVblotei-------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2 700) Use Emolovee Nausine/Labor Camo Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmenta: .ssessment ❑ UST-CAP Site ❑ Local EIW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site ❑ ,abandoned HSV Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Poot/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—.Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registrarion# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Proms/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10--❑ It -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E110069 Blue Anolication Form EMERGENCY ('NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRA.yt ELEMENT FEE ❑ Su rcharge FEE ❑ Other FEE INSPECTOR# PERNfr VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE n ❑ Cash REVREwED BY ACCOUNTING OFFICE Date EH 0069 PINK FOP-M.doc Rev. 7/07/99