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SAN MkQUIN COUNTY ENVIROMMENTAL HEALTH DIVISION <br /> M-4STERFILE RECORD hYF0R1NL&TI0iY FORM(EH 00 69) <br /> New EH Pro ac Existing Facility - " ❑New EH irograms,and New Facility - <br /> Facility ID C)0 rL3Q ProaramRecordED A< O5�/910 , . ' <br /> Facility Address °l01 �' A r C yT P At'l WA-1 <br /> (Please Check the appropriate description and specify size number of units and pertinent information <br /> .) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity_ Square Footage Food Handlers Course ree uked: Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vendingl4lachinea-N6mberofUnits ' <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 S License it Sticker R <br /> Cl Temporary Food Facility--Dates of operation from to Cl 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 /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit Cl Permit-By-Rule Household Hazardous Waste <br /> �(aBOVEGROUND STOP AGE TANK FACILITY(AST)(2390)—Number ofAST 3 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUjvIotel---Numberof Units ❑Jailor ExemptInstitution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp.tonlicarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment Cl UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number o(Pools/Spas at Faciliry ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Kennel <br /> ❑ Poultry Farm—Maximum numberofbirds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooiag(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License ft Capacity Vehicle <br /> [] pumper Vehicle-Regisaarian# _ <br /> ❑ Pumper-Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units — <br /> SOLID WASTE PROGRAM(4400) - ❑ Slud etAsh Site <br /> ❑ Landfill ❑Transfer Station ❑Ag/CanneryWasteSite g <br /> ❑ Process(Re cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility [I Compost Facility cY tY <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units - ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) - <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator _ ❑Small Generator ❑ Limited Hauler, <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑2-t0--❑ 11-60-0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Applicadon Form - - - - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM - <br /> CONTACT PERSON R"A�7 Rmr-�oA AI­p Day Ph !R SSl- .-702e—( Night Ph <br /> PROGRAM ELEhIFM Z 39 D FEE Surchargeyir .❑Other FEE <br /> ICISPECTORor1�_ PFRMrrVALID - - to - [3 Food Handler <br /> 11Check p AiISDIM PAID Date INVOICE =-- <br /> ❑Cash REv[EwED BY ACCOUN tING Opt Date <br /> . - -. Rev.0797199 <br />