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SA` JOAQUIN COU'L TY F- "R0TNALIENTAL HEALTH DIVIS� <br /> tiLkS-:ER-FILE REC0 ul uv-'OR-NLA,TION FORM(EH 00 69) <br /> ,XN,-u•EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID FA 00WH O Program Record ID <br /> Facility Address 095 15-6 DOW" <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 ❑ 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 T License R Sticker <br /> ❑ Mobile Food Prep Unit–Make Vehicle Type Color <br /> Registration T License R Sticker <br /> ❑ Temporary Food Facility--Dans 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 /> FLkZARDOUS 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 ❑ PermiBy-Rule Household Hazardous Waste <br /> XkBOVEGROUND STORAGE TANK FACILITY(AST)(3390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(3300)Use UST,4 cnd B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoreUi<(otel----`lumber of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2/00) Use Emplovee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 of Pools/Spas at Facility Cl Pool C3 Spa C3 Out of Service PooUSpa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4-000) <br /> C1 Poultry Farm Maximum number of birds Cl Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 t) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle–Registrarion T License Capacity Vehicle T <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site C3 SiudgelAsh 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 ❑ Farm/Raach Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> C3 Primary Care C1 Acute Care [I Skilled Nursing C1 Large Generator C1 Small Generator C1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Avplicariort Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA.Nt ELEb1ENT'2–N O FEE ❑ Surcharge FEE ❑ Other FEE <br /> D(sPECTORn PER.sirr VALID to ❑ Food Handler__ <br /> ❑ Check z A-MOIP`�T PAM Date INVOICE m <br /> ❑Cash PEVtE'%vED B 2(Q ACCOUNTING OFFICE ( Date <br /> - Rev.07r07i 99 <br /> EH 0469 PNK FORIM.doc <br />