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40 40 <br /> SA.N JOAQUIN COUNTY ENVIRONNNIENTAL HEALTH DIVISION <br /> NLASTERFILE RECORD Ii 1FORTNIATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID o0_3 7 7 Program Record ED <br /> Facility Address �� �T d <br /> (Please Check the appropriate description and specify size,number 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 /> Cl Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> C1Temporary Food Facility-----Dates of operation from to C1 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 /> 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 /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application 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 ClPool C1 Spa C1 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [I Tattooing(4121). [3 Body Piercing(4120) C1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration# License# Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ SludgelAsh Site <br /> C1 Landfill C1 Transfer Station El Ag/Cannery Waste Site b <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 /> [I Primary Care [I Acute Care C1 Skilled Nursing 13 Large Generator C1 Small Generator C1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic 11Common Storage Facility —1:12- 10--C3I 1 -60—13 >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 /> PROGRau,vl ELEM NT -l 1 kEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# I PER.%irr VALID to ❑ Food Handler <br /> ❑ Check# AM9UNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> Rev.07/07/99 <br /> EH 0069 PINK FOR-M.doc <br />