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Aw <br /> SAN JOAQUIN COUNTY ENVIRONMAENTAL•HEALTHD IVISION <br /> MASTERFME RECORD L`IFADMATWIN FOR1V1(EH 00 69) <br /> ❑New EH Pro at Existin2 Facility <br /> ❑New EH Program and New Facili <br /> Facili ID Aop Program Record ID 4FU� l3 <br /> Facility Address <br /> (Please Check the appropriate description and specify jLze,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yrs❑ No ❑ <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> []Vending Machines—Number of Units <br /> C] Commissary C3 Dry stooge only El 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 VeLicense# Sticker <br /> Registration X Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License Sticker# <br /> Registration# ❑ Ice Plat <br /> ❑ Temporary Food Facility--Daces of operation from to C3 Produce Stand <br /> ❑ Special Event - Dates of operation from to <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 /> HA,ZAF,DOUS WASTE PROGRAM(2200) Toss Generated Per Year <br /> C <br /> [Hazardous Waste Generator------------------ <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 AM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> El Hotel/Motel-----Number of Units <br /> Application Form <br /> Employee Housing(2700)Use Employee Housin/Labor Camp <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ UIC Site <br /> Cl Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> El Pool ❑ Spa ❑ Out of Service Pool/Spa El Natural Bathing Area <br /> Number of Pools/Spas at Facility <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(4121) ❑ Body Piercing(41 20) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> [I Pumper Vehicle—Registration# License m P tY <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑A /Canal Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station g Jt.ry ❑ CIA Landfill Site <br /> ❑ Compost Facility ❑ Process/Re cle Facility <br /> ❑ Waste Tire Facility P ❑ Farm/Rs ich Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ SmallGenerator [3 Limited generators <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility <br /> -112 <br /> ❑ 7- ❑ <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> PRDORAbIELEMENT ao FEE ❑ Surcharge FEE [IOther FEE <br /> PERMIT VALID-_ to •❑ Food Handler <br /> INSPECTOR# y�♦OICE# <br /> AMOUNT PAID . Date <br /> ❑ Checks Date (1- 10 <br /> ❑ Cash REvIEWED BY ACCOUNTING OFFICE <br /> Rev.07107/99 <br /> EH 0069 PINK FORM.doc <br />