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SAN JOAQUIN COLS TY , RON"MENTAL11EALTHDIVISQN <br /> NLASTERFILE O CORD L`IFORNLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility IDEA QM01 to 12, Program Record ID <br /> FacilityAddress )?-50e. MOA V-LAL! Ga- MCI <br /> (Please Check the appropriate description and specify side rrumber of units and oertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs ❑ 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 /> Registration R License m Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License# Sticker m <br /> Cl 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 /> Cl Hazardous Waste Generator------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Condirionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ PerrttiBy-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and 8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUDlotel-----—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2 700) Use Emplovee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local EEW 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 ❑ Pool Cl Spa Cl Out of Service Pool/Spa ❑ Narural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry farm—Maximum number of birds ❑ 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 k Capacity Vehicle R <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 ❑ CW Lan drill 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 ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veteriaary Clinic ❑ Common Storage Facility —112-10—❑ It -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELE tENNT 2'MD FEE ❑ Surcharge FEs ❑ Other FEE <br /> LVSPECrORX PERdtIT VALID to ❑ Food Handler. <br /> ❑ Check# ADIOUNT pAID Date INVOICE"m <br /> ❑ Cash REVIEWED BY 111Accourr ciOFFICE Date <br /> EH 0069 PINK FORIM-doc Rev.07/07/99 <br />