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SAN JOAQUIN COUNT`-%NVIRONMENTAL HEALTH DIV ION <br /> NTASTERFILE RE D INFORMATION FORM (EH 00 69) <br /> t - <br /> \Icw EH Pro¢rair at ExistingFacility ❑New EH Pro gram and',Ncw Facility <br /> 4 <br /> Facilit ID Program Record ID � <br /> p <br /> Facility Address — <br /> (Please Check the appropriate description and specify size,number of its and pertinent inform tion.) <br /> FOOD PROGRAM(1600) i{ <br /> ❑ Restaurant: Stating Capacity Square Footage Woo Handlers Course required: YES❑ No ❑ <br /> f <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation '�©Vending Machines--Numbcr 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# 11L. Sticker# <br /> I ❑ Mobile Food Prep Unit--Make Vehicle Type 1F Color <br /> E Registration# License# Stickcr# <br /> El Temporary Food Facility-----Dates of operation from i) to:i' ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from to E " ❑ Produce Stand <br /> DAIRY PROGRAM (2000) !!f 1 <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispensicr---Numbcr of Containers in Multi-Head Unit <br /> Il, <br /> CUPA ❑ State Facility Surcharge(2399) a <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> f ❑ Hazardous Waste Generator----------Tons Generated Per Year I ❑ RecycIe 1 Exempt System <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) +❑ Conditionally Exempt(CE) <br /> ❑ Pergtit-By-Rule Fixed Unit ❑ Pe "t-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Numbcr of AST a <br /> UNDERGROUND G OUND STORAGE TANK US PROGRAM 2300 Use LISTA and I3 or <br /> fir'a <br /> HOUSING PROGRAM(2400) 3j <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution--Numberof Units <br /> Employee Housing(2700) Use Employee Housiujz/Lgbor Camp Application Form "; <br /> MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ivironmental Assessment ❑ UST-CAP'Site © Local W Icanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> bandoned HW Site ❑ non-NPL/SEP Cleanup Site RWQCB Cleanup.[Sitc ❑ Water Quality Remediation Site <br /> R CREATIONAL HEALTH PROGRAM(3600) i 3 0 0 <br /> Number of Pools/Spas at Facility ElPool ElSpa' ❑ Out of Service Pool/spa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) # <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> �i <br /> TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM(4[00) - <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) + ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ <br /> Pumper Vehicle P.,--Registration# License# 1� Ca .�cit Vehicle# <br /> P g Y <br /> 1:1 Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilcts-------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/Ree cle}Facility ❑ <br /> CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpstcrs>20 cu yd----Numbcr of Units ❑ Farm/Ranch Cleanup Site f <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> f ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility=----❑:�2- 10-------❑ It -60------11 >60 generators i <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS EFI0069 Blue Apnlicarion Form <br /> ]EmI RGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph I j Night Ph <br /> PROGRAM ELEMFYI FEE ❑ Surcharge FEE '1 ❑ Other FEE <br /> INSPECTOR PERMIT VALID to i ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REviEWED 13Y ACCOUNTING OFFICE 1 Date <br /> sr <br /> EH 0069-Pink Form 1'A ;I Rev.02/25/03 <br />