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r- <br />11 SAN JOAQUIN COUNT_NVIRONNti1ENTAL HEALTH DI's __.ON <br />YLASTERFILE RECORD Iii iFORNLAMON FORN1(EH 00 69) <br />New EH Program at Existing F,a,ciliry ❑New EH Program and New Facili <br />Facility 1D "J716�—+�J Program Record ED <br />Facility Address /0 ��A <br />(Please Check the appropriate description and specify size, number of units and pert <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑ Retail Market ----Square footage <br />❑ with Meat Market only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type — <br />Registration # <br />License # <br />❑ Mobile Food Prep Unit --Make <br />_ <br />Vehicle Type — <br />Registration # <br />License # <br />_ <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event - Dates of operation <br />from to <br />Y!! <br />�raft tm aw <br />Co, <br />Food Handlers Course required: YEs ❑ No ❑ <br />❑ Vending ,Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />W <br />❑ Ice Plant <br />❑ 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 ❑ Permitslyi -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 orms(l <br />HOUSING PROGRAM (2400 <br />❑ HoteUMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housin /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 Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural 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 # Capacity Vehicle # <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 C1 CIALandfill 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 ❑Veterinary Clinic ❑ Common Storage Facility --❑ 2 - 10 ---- ❑ 11 - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY A D/OR PROGRAM <br />CONTACT PERSON Day Ph ,� /��� Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERUMIT VALID to ❑ Food Handler <br />❑ Check # Amo T PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />EH 0069 PINK FORM.doc Rev. 07/07199 <br />