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SAti JOAQUIN COU'L TY 'IRONNIENTAL HEALTH DIN7* <br />NLASTERFELE RECORD LNFORtiLaTiON FORtiI (EH 00 69) <br />19"New EH Program at Existing Facility ❑New EH Pro and Yew Facility <br />Facility IDFA DOI CAL+LA Program Record ID <br />Facility Address 9GO W. MDSSGtaLQ i2oGtd, CCA;t- V- D <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />�Mvm5a(&& <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YFs ❑ No ❑ <br />El Commissary C1 Dry storage only ❑ with Food Preparation ❑Vending iMachines —Number of Units <br />❑ Retail Market ---Square footage ❑ with Nfeat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ :Mobile Food Vehicle ---Make Vehicle Type Color <br />Registration R License R Sticker;. <br />C3Mobile Food Prep Unit --take Vehicle Type Color <br />Registration T License R Sricker <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event - Dates of operation from to <br />❑ Ice Plant <br />❑ 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 />_f <br />C1Permit-By-RuleFixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />L'1 ABOVEGROUND STORAGE TANK FACILITY (AST) (3390)—Number of AST 4_ <br />U`iDERGROIND STORAGE TANK (UST) PROGRANI (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ HoteUi♦fotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee Housing/Labor Camp Aoplication Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HIV 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 of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds C1 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 T License # Capacity Vehicle T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />F-1Landfill C1 Transfer Station C1 Ag <br />CIA LAg / Cannery Waste Site [1 IA landfill <br />Site <br />C1 Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility andfill Site <br />h d <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ FarmfRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />C1 Primary Care 11 Acute Care ❑ Skilled Nursing C1La pe Generator El Small Generator 11 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 Am7lication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRA.vt ELE,r1E`lTe2D FEE ❑ Surcharge FEE ❑ Other FEE <br />IvsPEc-roR# PERMIT VALID to ❑ Food Handler__ <br />❑ Check k <br />❑ Cash <br />REVIEW -ED <br />EH 0069 PILAF: FOR.M.doc <br />Amon, —r PAIDDate <br />,a.0A AI?? I �/ I ISTD ACCO[MING OFFICE <br />INVOICE T <br />Date <br />Rev, 07/07199 <br />