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SANT JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVIS.ON <br /> NLASTERFILE RECORD LNFOILVIATION FORNI(EH 00 69) <br /> ❑ New EH Program at Existing Facilitv ❑New EH Program and New Facility <br /> Facility ID 00o b 1Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size-number of units and pertinent information.) /1 S <br /> FOOD PROGRAM(1600) - 1 <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course reouired: Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Mea[Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> to <br /> El lee Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> El Special Event - Dates of operation from to . <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeoser—Number of Containers in Multi-Head Unit <br /> — <br /> CUP ❑ State Facility Surcharge(2399) ^ / <br /> ji,AZA OUS WASTE PROGRAM(2200) i2�„[ L <br /> azardous Waste Generator------ Vl ons Generated Per Year <br /> low <br /> Tiered Permitting Facility ElConditionally 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 /> ❑ Jail or Exempt Institution—Number of Units <br /> C3 HoteVNlotel-----—Number of Units <br /> Employee Housing(2700) Use Employee Housir /Labor Cama Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPWSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa Cl Out of Service Pool/Spa ❑ Natural Bathing Area <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) Vehicle# <br /> ❑ Pumper Vehicle—Registration R <br /> License# Capacity <br /> [I Pumper Yard <br /> El Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> [I❑ Process/Recycle Facility CIA Landfill Site <br /> El Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care C3 Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ L l 60—11 >60 generators <br /> 11 Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ --- <br /> 2- 10 <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 /> FEE ❑ Surcharge FEE [I other FEE <br /> PROGRAM ELEMENT ❑ Food Handler <br /> INSPECTOR# X S I PERmrr VALID t0 <br /> Date INVOICE# <br /> C1A,�IOIJNT PAID Check# kLlDate o�P1� <br /> ❑ Cash REVIEWED BY ACCOUNRNO OFFICE <br /> Rev.07/07199 <br /> EH 0069 PINK FORM.doc <br />