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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />NLASTERFILE RECORD Ili 1FORNIATION FORNI (EH 00 <br />!New EH Pro am at Existing Facility ❑New EH Pro am and New Facili <br />FaciIi ID rA 6,16 J 7 qGt Program Record ID % <br />Facility address <br />(Please Check the appropriate description and specify size • number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Food Handlers Course requireYes C3 No C1 <br />C1 Searing Capacity Square Footage <br />d: <br />C1 Commissary ❑ Dry storage only 11 with Food Preparation ❑Vending Machines —Number of Units <br />Li Retail Market ----Square footage C3 with Meat Market only El Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ---Make <br />Registration # <br />❑ Mobile Food Prep Unit --Make <br />Registration # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event - Dates of operation from <br />Vehicle Type <br />License # <br />Vehicle Type <br />License # <br />to <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />C3 Milk Dispenser—Number of Containers in Multi -Head Unit <br />C3 Grade A Dairy C1 Grade B Dairy <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />Hazardous Waste Generator ----------------------Tons Generated Per Year ` <br />Tiered Permitting Facility C1 Conditionally <br />Peri BY 1Rue Fixed Unituthorized ❑ Permit -By Conditionally <br />e Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑Jail or Exempt Institution Number of Units <br />C3 HoteUivlotel------- Number of Units <br />Employee Housing (2700) Use Employee Nousinz/Labor Camp App(icatlon Form <br />UNDERGROUND INJECTION CONTROL(3000) <br />SITE MITIGATION (2900) <br />C1Environmental Assessment C1 UST -CAP Site ❑ Local HW Cleanup Site C3NPL/SEP Cleanup Site [I 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds — <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # _ <br />❑ Pumper Yard <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />License # Capacity Vehicle # <br />❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash e/Ash Site <br />C3 Landfill C1 Transfer Station C1 Ag /Cannery Waste Site g <br />❑ Process/Recycle cle Facility ❑CIA Landfill Site <br />C1 Waste Tire Facility ❑ Compost Facility y C1 Farm/Ranch Cleanup Site <br />❑ Refuse Vehicles —Number of Units ___ ❑ Dumpsters > 20 cu yd —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />C1 Primary Care C3 Acute Care ❑ Skilled Nursing C1 Large Generator C1 Small Generator ❑ Limited Hauler <br />Common Storage Facility —❑ '_ - 10 <br />C1 I - 60 —❑ > 60 generators <br />❑ Transfer Station ❑ Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON <br />Day Ph <br />Night Ph <br />PROGRAM ELEMENT <br />FEE r ❑ Surcharge FEE L_l Utner r nr. <br />PERMIT VALID / to 1 ❑ Food Handler—� <br />INSPECTOR # �' t <br />❑ Check # <br />AIMOUNT PAID <br />❑ Cash REVIEWED BY <br />FH 0069 KNK FORM.doc <br />Date <br />ACCOUNTING OFFICE '! <br />INVOICE # <br />Date <br />Rev. 07/07"99 <br />