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SAN JOAQUIN COUNTY ENVIRONMENTAL"HEALTH DIVISION <br /> YIASTERFILE RECORD I'iNFORIMATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> F a c i I i ty ID ��:t: �i�?.l Program Record ID Q-0,S71 1 <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: Yes❑ No 11 <br /> El Seating CapacitySquare ga <br /> [I Commissary El Dry storage only C3 with Food Preparation ❑Vending Machines—Number of Units <br /> El Retail Market----Square footage ❑ with Meat Market only C3 Multiple Departments El Prepackaged Goods Only <br /> Color T <br /> Type C1 Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License# <br /> T <br /> ype Color <br /> ❑ Mobile Food Prep Unit--Make VehicleSticker# <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> C3 Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C3 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> RAZAB60US WASTE PROGRAM(2200) L G> --vo N3�, <br /> d Hazardous Waste Generator--------------------Tons Generated Per Year <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 PROGRAM(2400) <br /> [1 Jail or Exempt Institution Number of Units <br /> C] IloteUiylotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ElUST-CAPSite ❑ Local HNV Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned NW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) Area <br /> Number of PooWSpas at Facility El Pool ❑ Spa C1 Out of Service PooUSpa ❑ Natural Bathing <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(4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# P tY <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C1 Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility C1 CIA Landfill Site <br /> El Waste Tire Facility C3 Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ElDumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care C3 Acute Care El Skilled Nursing ❑ Large Generator C3 Small Generator 11jlmt� ed Hauler <br /> El Transfer Station ❑ Veterinary Clinic <br /> (I Common Storage Facility —❑ 2- 10--C31 l -60—060 <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E Rg Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> PROGRAim ELEh1ENT 22:- FEE <br /> 11 Surcharge FEE [I Other FEE <br /> �'" PERMIT VALID �4� �D <br /> to <br /> ❑ Food Handler�� <br /> IYSPECTOR# Z_ Date <br /> ❑ Cash REViE�VED BY INVOICE a <br /> 11Check# A.ML OUNT PAID <br /> ACCOUNTING OFFICE Date5 0 a <br /> Rev.07/07/99 <br /> ��nMIV rnom.ins <br />