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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> ;VIASTERFILE RECORD Ii IFORNI�.'TIOY FORN1(EH 00 69) <br /> New EH Program at Existing Facility <br /> ❑New EH Program and New Facility <br /> Facili ID Program Record ID5/ SSU <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number o_f units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course req_ u_ iced_ YEs❑ NOCI <br /> C3 Restaurant:Restaurant: Seating Capacity q g ❑Vendin Nfachines—Number of Units <br /> C3 Commissary C3 Dry storage only Cl with Food Preparation g <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# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> C3Temporary Food Facility--Dates of operation from to LlProduce Stand <br /> C3Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> 13Grade B Dairy [3 iVlilk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Tons Generated Per Year L <br /> Hazardous Waste Generator---------------------- <br /> Condition <br /> ly Exempt <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) Permit-By-Rule a1Household Hazardous Waste <br /> C1Permit-By-RuleFixed Unit <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 /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HotellMotel-------Number of Units <br /> mp Application Form <br /> Employee Housing(2700) Use Employee Housin-/Labor Ca <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> C3Environmental Assessment [3 UST-CAP Site nu Site Local HW CRWQCB Cleanupleanup Site ❑Si NPWS❑P Clean up Quality Remediation Site <br /> C1 Abandoned HSV Site ❑ non NPL/SEPCleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM P <br /> (4200) License# Capacity Vehicle# <br /> [:1 Pumper Vehicle—Registration# <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant C1 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) [ISludge/Ash Site <br /> 11 Landfill <br /> C1 Transfer Station C1 Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> C1 Waste <br /> Process/Recycle Facility Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> Cl Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ I L -60—❑>60 generators <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing C3 Large Generator ❑ '- 1❑ Small Generator C3 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility -- - <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use <br /> PWS EH0069 Blue Application Form <br /> � 5 W EMERGENCY NOTIFICATION FOR THIS FACILITY AI IOR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> 7�� ❑ Surcharge FEE ❑ Other FEE <br /> PROGRAM ELENIENT ZZ Z 0 FEE ❑ Food Handler_______�— <br /> PERMIT VALID t0 <br /> INSPECTOR# INVOICE# <br /> AMOUNT PAID Date <br /> ❑ Check# ICA Date <br /> ❑ Cash REVIEWED BY ACCoUWING OFFICE Rev.07/07199 <br /> EW0069 PINK FORM.doc <br />