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F`� <br /> AQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> IKkSTERFILE RECORD INFORIVLkTION FORIYI(EH 00 69) <br /> New EH Program at Existing Facility - ' ❑New EH irograrn and New Facility , <br /> Facili ID 00-yow 00-yoProgram Record ED <br /> Facility Address q 39� 6 . 9"Ack, C"MP Qj) <br /> (Please Check the appropriate description and specify s%number of units and pertinent informntion.) <br /> FOOD PROGRAM(1600) .. `. -4. . .. <br /> ❑ Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YEs❑ NO ❑ <br /> ❑ Commissary ❑ Drystorage 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 R License 4 Sticker R <br /> Cl Mobile Food Prep Unit—Make Vehicle Type - Color <br /> Registration X License# Sticker <br /> ❑ 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-----------Tori Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> Cl Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardou Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST _ <br /> UNDERGROUND STORAGE TANK(UST)PROGRALM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hoteuiylotel---Number of Units ❑ Jail or Exempt Institution—Number of Units - <br /> Employee Housing(2700) Use Employer Nousiap/Lahor 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 ❑ 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Zi2ruml Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum numberofbirds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ Pumper Vehicle—Registrarion# License Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Pilot ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) t - <br /> - - <br /> ❑ Landrin ❑Transfer Station 0A/Cannery Waste Site - ❑ Sludge./Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility . ❑ Process/Recycle Facility ❑ CIA Landfdl Site <br /> ❑ Refuse Vehicles—Number of Units * ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmfRauch 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- 10—❑ 11-60—❑>60generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANOIOR PROGRAM ' <br /> CONTACT PERSON e. R4 Day Ph9 R?552 Night Ph <br /> PROGRAM ELEMENT— FEE SurchargesFEE ❑ Other FEE <br /> IYSPECTORYr 533► PERMIT VA _ to - --� -- _❑Food Handler <br /> ❑ Check# AMOUn PAID Date - ss INVOICE}? _. <br /> ❑ Cash REvtE%VFDBY . ACCOUNTING OFRE l 20 L-- Date /4 /7 'E <br /> gvaY07"99 <br />