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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> �LaSTERFII E RECORD PIFOR�L4TION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facile <br /> Facility ID Program Record ID oJ <br /> Facility Address <br /> (Please Check the appropriate description and specify size'number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Food Handlers Course required: YES 'NO <br /> ❑ Restaurant: Searing Capacity Square Footage <br /> ❑ ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendiog Machines-Number of Units <br /> ❑ Retail Nlarket—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C3 Mobile Type Color.Mobile Food Vehicle--Make License# Sticker# <br /> Registration# <br /> Vehicle Type Color. <br /> ❑ Mobile Food Prep Unit-Make License# Sticker# <br /> Registration# ❑ Ice Plant <br /> C30 Temporary Food Facility--Dates of operation from ❑ 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 /> COPA ❑ State Facility Surcharge(2399) / (tel <br /> 4ZA OUS WASTE PROGRAivi(2200) 22� � G J <br /> azardous Waste Generator---- - ons 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 USIA and 8 farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> C3 HoteU�lotel-------Number of Units <br /> Emptoyee Housing(2700) Use Employee fTo—,jyii—,-1Labar Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site 11 Local HW Cleanup Site 13NPLISEP Cleanup Site ❑ OIC Site <br /> ❑ Abandoned HW Site 11 non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing area <br /> Number of PooWSpas at Facility Cl Pool ❑ Spa C3 Out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11 Tattooing(412 1) <br /> ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> C3 Pumper Vehicle-Registration# <br /> License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant C1 Chemical Toilets---Number of Units� <br /> SOLID WASTE PROGRAM(4400) ❑ A /Cannery Waste Site ❑ Sludge/Ash Site <br /> C3 Landfill LI Transfer Station g n' <br /> ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> C3 Waste Tire Facility C1 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 /> C3 Primary Care 11 Acute Care C1 Skilled Nursing 13 Large Generator ❑ I I 60—13>60 generators <br /> C3Transfer Station C3Veterinary Clinic El Common Storage Facility —112- 10— <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> FEE ❑ Surcharge FEE [3 Other FEE <br /> PROGRAM- ELE1vtENT [3 Food Handler <br /> INSPEtTGR# t//�_ PERh1IT VALID t0 <br /> INVOICE#te <br /> ❑ Check# AMOUNT PAID Da ' <br /> ACCOUNTING OFFICE Date <br /> ❑ Cash REVIEWED BY Rev.07107199 <br />