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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIMS ON <br /> MASTERFILE RECORD INFORriLATION FORNI(EH 00 69) <br /> New EH Pro am a[Existin Facility <br /> ❑New EH Pro and New Facility <br /> Facili ID 3 <br /> Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify-size•number of units and Pertinent information.) <br /> FOOD RoGRAM(1600) Food Handlers Course required: Yes ❑ No ❑ <br /> [I Restaurant: Seating Capacity Square Footage <br /> ❑Vending Machines—Number of Units <br /> C] Commissary C1 Dry storage only <br /> ❑ with Food Preparation <br /> ❑ Retail Market----Square footage_ ❑ with Meat Market only ❑ Multiple Departments ❑ 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 Plan[ <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> to <br /> DAIRY_PROGRAM (2000) C3 Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUPA ❑ State Facility Surcharge(2399) L *SNS <br /> R_AZAIjDOUS WASTE PROGRAM(2200) __Togs Generated Per Year <br /> &'Hazardous Waste Generator------------------ ❑ Conditionally Exem t(CE) <br /> Y P ( <br /> Tiered Permitting Facility O Conditionally Rulleuthorized e 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,4 air"—'s <br /> HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution—Number of Units <br /> ❑ HoteVMotel-------Number of Units <br /> Employee Housing(2 700) Use E piovee H unit �/L bor Camp Application Form <br /> UNDERGROUND UNJECTION CONTROL(3000) ❑ UIC Site <br /> SITE MITIGATION(2900) UST-CAP Site Site <br /> C3 Environmental Assessment 0 non-NPL/SEP Cleanup Site I ❑CRWQCB Cleanup❑Sit PSS❑ Water Quality Remediation Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ put of Service Pool/Spa ❑ Natural Bathing Area <br /> ❑ Pool ❑ Spa <br /> Number of pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) Cl Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) <br /> ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> License It <br /> ❑ pumper Vehicle—Registration# _�— ❑ Chemical Toilets—Number of Units_�— <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> , <br /> SOLID WASTE PROGRAM(4400) 13 Ag <br /> Site <br /> ❑ Transfer Station 13 Ag!Cannery Waste Site D CIA Landrdl Site <br /> ❑ Landfill ❑ procPss/Recycle Facility <br /> ili <br /> ❑ Compost Facility ❑ FarmirRanch Cleanup Site <br /> ❑ Waste Tire Facility P [I Dumpsters>20 cu yd—Number of Units <br /> ❑ Refuse Vehicles—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ I I -60—❑ >60 generators <br /> ❑ Primary Care ❑ Common Storage Facility -❑ 2- 10 <br /> ❑ Transfer Station ❑ Veterinary Clinic _ <br /> PUBLIC WATER SSTEM PROGRAM(4600) Use PWS EH0069 Blue Applicafion Form <br /> Y <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph� Night Ph <br /> rCONTACT PERSON ❑ Other FEE <br /> ❑ Surcharge FEE <br /> .�.-�—�� FEE�� _, /'—� / ❑Food Handler <br /> GRAM EL�(E"��MEC�N'�T �— i r to <br /> ECTOR# �52� PERMIT VALID t/! INVOICE#Dateheck#�— Ail10IJNT'PAm —�� 7 2`� �_J Dateash <br /> REVIEWED BY ACCOUNTING OFFICE Rev.0710 <br /> _......1,.�n.,v cnom Ane <br />