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SAN JOAQUIN COUNT'S ENVIRONMENTAL HEALTH DII :ON <br /> 1VIASTERFILE RECORD LNFORINLATION FORK H 00 69) <br />PFrE_11 New EH Program at Existing Facility ew EH Program and New Facility <br /> Facility ID ,r, ' Program Record ID i <br /> Facility Address vta✓-� <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yes Cl 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# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility---Dates 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 /> HAZARD VASTE PROGR%,Nl(2200) <br /> Wflazardous Waste Generator ---------------------Tons Generated Per Year <br /> /T'i'ered Permitting Facility ❑ Condirionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(3390)--Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST,4 and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUMotel-------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 ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> Cl Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility Cl Pool C1 Spa C1 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C] Tattooing(412 1) ❑ Body Piercing(4120) C1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4100) <br /> El Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Siudge/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 ❑ FaraVRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 11 Transfer Station C3 Veterinary Clinic ❑ Common Storage Facility -113- 10--❑ l l -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EF-10069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELENIEN� FEE ❑ Surcharge FEE ❑ Other FEE <br /> hseerroR# PERMIT VALID 6 to T ❑Food Handler <br /> C1Check# AIMOUNT PAID <br /> Date INVOICE# <br /> ❑ Cash RFvIEWED BY ACCOUNTING OFFICE Date <br /> Rev.07/07i99 <br /> EH 0069 PINK FOFLM.doc <br />