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♦SA1N JOAQUIN COUNT ENVIRONMENTAL HEALTH D ON <br /> MASTERFILE RECORD LYFORALkTION FORlvl(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID QD o` Program Record IDp " <br /> Facility Address <br /> (Please Check the appropriate description and specify size.number or units and pertinent information.) <br /> FOOD PROGRAM(1600) - <br /> ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yrs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Veading Nlachines-Number of Units <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vebicle--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> C1 Tempo rary Food Facility--Dates of operation from to 11 Tee 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 /> HAZARDO S WASTE PROGRAM(220 <br /> P-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 /> ❑ HoteViv[otel-------Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Homing/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 /> ❑ PumperVehicle-Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) t - -- - _ <br /> ❑ Landfill ❑ Transfer Station ❑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 to 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 6)) �1oy1 BIZ rnlT- <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM YOK ID-�yrE3 <br /> CONTACT PERSON Day Ph Night Ph` t9 /�( <br /> PROGRAMELEMENT FEE ❑SurchatgcfEE ❑ Other FEE <br /> Ir/SPECrOR# PERMIT VALID I - I -O, to_ /, -. i�'I-� ❑Food Handler <br /> ❑ Check# AMOtM PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUMIItG OFFICE -Date <br /> EH 0069 PINK FORM.doc - - - R,,.07/07,199 <br />