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SAN JOAQUIN COUNTY ENVIRONMENT.A-L HEALTH DIVISION <br /> LNLASTERFILE RECORD LNFORNLaTION FORM(EH 00 69) <br /> New EH Pro am at Existing Facilitv ❑New EH Program and New Facility <br /> Facility ID Program Record ID . 0515 71D <br /> Facility AddressCIS <br /> (Please Check the appropriate description and specify size,num er of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity 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 /> Registration# License# Sticker <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration License# 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-----------------------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 /> XABOVEGROUND STORAGE TAiINK FACILITY(AST)(2390)--Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> C1Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp ADDlication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW 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 Cl Pool El Spa C3 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11Poultry Farm Maximum number of birds 1:1 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 /> Cl Pumper Vehicle—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill C1 Transfer Station C3 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 /> C1Primary Care ❑ Acute Care El Skilled Nursing C3 Large Generator ❑ Small Generator C1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic [ICommon Storage Facility —E] 2- 10--❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE — <br /> INSPECTOR# PEPUMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCO[NTLNG OFFICE Date <br /> EH 0069 P[NK FORM.doc /_ 0 3 —Q e_�Vo Rev.07,07i99 <br />