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SAN ,TOA QUIN COUN7'-4'�NVIRONMENTAL HEALTH DI N IIMASTERFILE RECORD INFORMATION FORM(EH 00 69) �3ms❑ New EH Program at Existing Facility ❑New EH Program and New Facilitytr} ! ^ Facility ID E Program Record ED Facility Address tgorvo i 'r�1t.Lk nf� TA& (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required; YEs Cl No ❑ I ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods only ❑ Mobile Food Vehicle-----Make Vehicle Type Color } Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility----Dates of operation'from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--Number of Containers in Multi-Head Unit I r CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year y Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) r ❑ Permit-By-Rule Fixed Unit ❑ Pen-nit-By-Rule Household Hazardous Waste /6 ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST f F UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and B dorms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Housin;/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) C1 Poultry Farm Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) Cl Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--dumber of Units ❑ Dumpsters>'_0 cu yd ---Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2- 10—--❑ 11 -60--❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS.EH0069 Blue Aaplicadon Form EMERGENCY(NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Y�2 A 1 0 FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handier�� ❑ Check# Ai ouNT PAID Date INVOICE# ❑ Cash REVIMVED nY ACCOUNITNG OFFICE Date EH 0069 PINK FORM.doc _M#* Rev.07107/99