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SAN JOAQUIN COUyi�, Y IRONMENTAL HEALTH DIV )N NIASTERFELE RECORD INFORitiL4TION FORM(EH 00 69) ❑ New EH PrograMar Existing Facility ❑New EH Pro am and New FaciIi { Facility ID Program Record IDI FaciIity Address 0-TO (Please Check the appropriate description and specify size, number of units and perrine information.) FOOD PR06RAM(1600) ❑ Restaurant: Searing Capaciry Square Footage Food Handlers Course required: Yes ❑ L14o ❑ ❑ 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 TypeColor Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Bead Unit CUPA ❑ 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 ❑ PeBy-Rule Household Hazardous Waste ,,kBOVEGROUND STORAGE THINK FACILITY(AST)(2390)--Number of AST �— UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST ! and H forms HOUSING PROGRAM(2400) ❑ Hotel/iMotel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Emploi ee Housbrg/Lahor Camp Aeolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UTC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/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--Registration# 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/Asb Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/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 -112 2- 10--❑ 11 -60—❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Form EMERGI=NG OTI ICATION FOR THIS FACILITY AND/OR PROGRAM 04 CONTACT PERSON V Day Ph -T /d Night Ph PROGR.A,M ELEMENT 13'7(% FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# / PERMIT VALID to ❑ Food Handler ❑ Check# A IMOU`rT PAID Date INVOICE# ❑ Cash REVIEWED BY f ACCOUNTING OFFICE Date EH 0069 PINK FORM-doc Rev.07/07/99