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SAN JOAQUIN COUNT—'NVIRONMENTAL HEALTH DIS ON <br />MASTFRFTT.F RECORD INFORMATION FORM (EH 00 69) <br />❑ New EH Program at <br />Facility ID j) l yQ 42 Y ja Pro4 <br />Facility Address c2/3 S. - <br />(Please Check the appropriate description and specify size• <br />FOOD PROGRAM (1600) <br />❑New EH Program and New <br />Record ID 2A I oZ 8' <br />and pertinent information.) <br />❑ Restaurant: Searing Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle -----Make Vehicle Type <br />Registration # _ License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type _ <br />Registration # License # _ <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event - Dates of operation from to_ <br />NPJS <br />s4,9, r <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 />to <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 />IR�ffazardous Waste Generator -----------------------Tons Generated Per Year 4-50 <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 `Implication 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 ❑ Pool ❑ Spa <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO. BODY PIERCING PERMANENT COSMETIC PROGRAM (4100 <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle--Registra[ion # License # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ 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 ❑ 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 --❑ 2 - 10 -- ❑ 11 - 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 />r-nnrrsi--r wrocnty Dav Ph Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />EH 0069 PINK FORM.doc 3 _3 0 — 4A9 -D cX,1 yjQ Kev. U iiu 7� <br />