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SAN JOAQUIN COU14 . ' ENVIRONMENTAL HEALTH D _BION <br /> NLASTERFH E RECORD LN'FORMATION FORM(EH 00 69) <br /> ❑New EH Pro and New Facility <br /> L ew EH Pro°ram at Existing Facility _ <br /> Facili ID \t>O' Pro°ram Record ED <br /> _ `L ' r l <br /> Facility Address , <br /> (Please Check the appropriate description and specify size•number of units and oerdnent information.) <br /> FOOD PROGRAM(1600) NO ❑ <br /> Square Footage Food Handlers Course required: YEs❑ <br /> ❑ Restaurant: Searing Capacityq ❑Vending Machines—Number of Units <br /> ❑ Commissary El Dry storage only <br /> ❑ with Food Preparation <br /> ❑ Retail Market----Square footage_ <br /> C1 with Meat Market only ❑ Multiple Departments [I prepackaged Goods Only <br /> Vehicle Type Color�— <br /> ❑ Mobile Food Vehicle---Make License# Sticker# �— <br /> Registration# Vehicle Type Color_— <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# �— <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility---Dates of operation from ❑ Produce Stand <br /> to <br /> 11Special Event - Dates of operation from _ <br /> DAIRY (2000) ❑ Milk Dispenser—dumber of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy El Grade B Dairy <br /> CUP A ❑ State Facility Surcharge(2399)_00) <br /> HAZARDOUS WASTE PROGRAM(22 t_- <br /> �' —Tori Generated Per Year <br /> Hazardous Waste Generator---------- ❑ Conditionally Exempt(CE) <br /> Y P <br /> Tiered Permitting Facility []Conditionally <br /> e�I oBy 1Ru e Fixed Unit CA) ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of ASF <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A— and Bons <br /> HOUSING GPS(2400) ❑ Jailor Exempt Institution—Number of Units <br /> ❑ HoteVivlotel-------Number of Units <br /> Employee Housing(2 700)Use E n lopee H uri =/L hor Camp A Iic°tion Form <br /> SITE Mt— TSN(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ UIC Site <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NYL/SEP Cleanup Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) pa❑ Spa C3 out of Service Pool/Spa C] Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> VECOR CONTROL PROGRAM <br /> T (4000) ❑ kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> zTIC TATTOO BODY PIERCING PERMANENT ❑ Body Pie <br /> c ROGRAM(4100) <br /> COSME og(40) [I Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) Capacity�-- Vehicle# <br /> License# �— <br /> ❑ Pumper Vehicle—Registration# �— ❑ Chemical Toilets—Number of Units <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) 0 Sludge/Ash Site <br /> ❑ Landfill <br /> ❑ Transfer Station C1 Ag/Cannery WastelitC1 process/Recycle Facilityy ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units 11 Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) a Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing Lang ❑ 2- 10--- <br /> ❑ f 1 -60--❑>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility — <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FORTHts FACILITY AND/OR PROGRAM <br /> Day Ph_�-- Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> ❑ Surcharge FEE <br /> [PROGRA�Ni ELEMENT22—X- FEE— �— tD ❑ Food HandlerECTOR# PE[ilvtfF VALID�— INVOICE#r�YIOUN-r PAID � Date <br /> heck# "� Dateash REVIEWED BY ACCOlO'rrMG OFFICE Rev.07/07!99 <br /> EH 0069 PINK FORIM.doc <br />