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r - <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV19MN <br /> NIASTERFII.E RECORD LYFORNL4TION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Prograrrt and New Facility <br /> Facility ID I �' J `/ Program Record ID )l�_c L l <br /> Facility Address <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) - <br /> FOOD PROGRAM(1600) _E_ - - - <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course rewired: 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 R <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 acilitySurcharge(2399) - L �`'V' Z Z I) <br /> H.A,ZAR.96US WASTE PROGRA 2200) <br /> Ct4lazardous 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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUMotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use EnsploEee HollsinelL4hor Camp Application farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IBV 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 PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Set-vice PaoUSpa ❑ 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# CapacityVehicle tf <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) 1 - - - <br /> ❑ Landfill ❑Tnusfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle 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 /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler. <br /> ❑ Transfer Station ❑ Veterinary 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 AND/OR PROGRAM _. <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGPLAIMELEhIENT ZZZU FEE 1(c { -y /t"�` ❑SurchargeFEE [3 Other FEE <br /> _ INSPECTOR# F,773 PERMIT VALID J to ❑Food Handler — <br /> ❑ Check# AMDIMPAID ,L l= lam Date i1'' INVOICE# <br /> ❑ Cash REViEtvEDBY ACCOUNDNGOFFICE Date : 2 03 <br /> EH 0069 PINK FORM.doc _- Rev.07107199 <br />