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f <br /> SAN JOAQUIN COL 'l. f ENVIRONINIENTAL HEALTH DI v ISION <br /> NLASTERFrLE RECORD L`IFORNIATION FORS[(EH 00 69) <br /> �TNew EH Program at Existing Facility ❑New EH Pro and New Facility <br /> Facility 1DFADO 10(5(I Program Record ED <br /> Facility Address I(OL- D S�A" 12cad <br /> (Please Check the appropriate description and specify sim number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs ❑ No ❑ <br />_ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License X Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker <br /> ❑ Temporary Food Facility--Daces of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ 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 /> FLAZARDOUS WASTE PROGRAM(2200) <br /> ,)Hazardous Waste Generator— ted -- Tons Generated Per Year tOO-St <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE <br /> ❑ Permit-By-Rule Fixed Unic ❑ 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 /> C3❑ HotellMotel----Number of Units Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp Application 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 PooWSpas at Facility ❑ Pool ❑ Spa [I Out of Service Pool/Spa Cl Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm—Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration T License X Capacity Vehicle k <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ 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—❑ it -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 /> CONTACT PERSON ^� Day Ph Night Ph <br /> PROGRAiyt ELEMENT 2� . FEE ❑ Surcharge FEE ❑ Other FEE <br /> NsPECLOR# PERMrr VALID to ❑ Food Handler. <br /> • <br /> andler — <br /> ❑ Check>r AMOUNT PAID Date INVOICE <br /> ❑ Cash REVIEWED BY <br /> AccoUN nNG OFFICE Date <br /> Rev.07/07/99 <br /> EH 0069 PINK F01UM.doc <br />