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SAN JO AQtiIN COifiTY E ONMENTAL HEALTH DIVISIA <br /> E,..,/ 'yLAS'I ERFII-E RECO FORVL4TION FOR:AI(EH 00 69) <br /> :New EH Program at Existing Facility ❑New EH Pro and New Facility <br /> Facility IDI Program Record ID 6)✓` //P /9e <br /> FacilityAddress 102?_ FrOrl:[ Q � I� <br /> (Please Check the appropriate description and specify sts;�e tuber of units and Dertinent information.) <br /> FOOD PROGRAM(t600) <br /> ❑ Restauraat: Seating Capacity Square Footage Food Handlers Course required: Yvs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Veading Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with blear Market only ❑ Multiple Deparanencs ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration 2 License p Sdcker m <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License R Sticker m <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Daces 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 /> KAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Condidonally 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 /> UNDERGROnD STORAGE TANK(UST) PROGRAM(2300)Use USTA and B(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housin;(2700) Use Emolovee Housing/Lahor Camo 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 /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Fools/Spas at Facility Cl Pool Cl Spa ❑ Out of Service Pool/Spa ❑ :Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number ofbirds ❑ 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—Registration License T Capacity Vehicle m <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Laadfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/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 ❑ 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 —112- 10—❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Anelication Form <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRASI ELEMENT D FEE ❑Surcharge FEE ❑ Other FEE _ <br /> LYSPECTORR PM%fIT VALID to ❑ Food Handler_ <br /> 13 Check AMOUNT PAID Date INVOICEI. .r _ <br /> ❑ Cash R`vlEwEo BY AccquvmrG OFFICE Date 0� <br /> EH 0069 PIN":FOR.M.doc Rev.07,07,99 <br />