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SAN JOAQUPt COUNTY IWROi NLENTAL HEALTH DIVIS�Y <br /> NL-kSTERFILE RECORD LNFOR:NLATION FOREVI(EH 00 69) <br /> New EH Pragrarn <br /> at Existio2 Facility ❑New EH Pro m and New Facility <br /> Facility ID t' DC00 y Program Record ED <br /> FacilityAddress <br /> (Please Check the appropriate description and specify size- number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capaciry 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 Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Regisrracion m License m Sticker T <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License R 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 ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator ------------------Tans Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-B Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—,lumber of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(3300)Use USTA and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hocel/`lotel-------Number of Units ❑ Jail or Exempt institution—Number of Units <br /> Emplovee Housing(2700) Use Employee ffousina�lLabor Camp Acgliaarion Form <br /> SITE MITIGATION(2900) UNDERGROUNO INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site Cl UIC Site <br /> ❑ .Abandoned HW Site ❑ oon-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number or Pools/Spas at Facility ❑ Pool Cl Spa ❑ Out of Service Pool/Spa ❑ :Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Kennel <br /> C1Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> C1 Tattooing(412 1) 11 Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle" <br /> ❑ Pumper Vehicle—Registraoon R License m Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud�elAsh Site <br /> ❑ Landfill ❑ Transfer Station 11 Ag/Cannery Waste Site e <br /> ❑ Process/Re cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility C1Compost Facility cY C1 Farm/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility —❑ 2- 10—❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Applicariort Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> YRDGRA.vI ELEb1ENT FEE 13 Surcharge FEE El Other FEE <br /> LVSPECTOR.Y PERbIFr VALID� to ❑ Food Handler_ <br /> ❑ Check A.MOU`7 PAID �� Date INVOICE m <br /> ❑ cash REVIEtiVED 8Y 3 �0 90 ACCOU,4TZ,'G OFFICE Date <br /> Rev.07107i99 <br /> EH 0069 PINK FOR..R.doc <br />