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ZZ <br />` SALIN JOAQUIIN COUNT VTRONMENTAL HEALTH DI N <br /> I. <br /> MAST ERFILE RECORD LNFORMATION FORIM(EH 00 69) <br /> ❑ New EH ProRT=at Eli xistin Facility ❑New EH Program and New Facili <br /> ty <br /> Facility ID PA D e153 I Program Record ID <br /> Facility Address I„ eAl KA kor- <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PR06RAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare Footage ' Food Handlers Course required: Yu❑ 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 /> ❑ <br /> Mobile Food Vehicle�h---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# <br /> P License# Sticker# <br /> ❑ Temporary Food Facility----Dates of operation from to ❑ Ice Plant <br /> C3 Special Event - Dares of operation from to ❑ Produce Stand <br /> 11 <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 1 ❑ 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 C1Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> 01BOVEGROUN:D STORAGE TANK FACILITY(AST)(2390)---Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USrA and S forms <br /> lI <br /> HOUSING PROGRAM(2400) <br /> ElHotel/iVlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Hou.ci i:1tabor CarnpApplication form <br /> SITE MITIGATION(29010) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site I ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ClPool ElSpa ClOut of Service Pool/Spa C3Natural Bathing Area <br /> Ii <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm MiI aximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) 1 ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration License# Capacity Vehicle# <br /> ❑ Pumper Yard 1 ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill I ❑=Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility !I ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—dumber of Units ❑ Dumpsters>20 cu yd --Number of Units ❑ FarM/Ranch Cleanup Situ <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—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> Emr=RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON �� Day Ph Night Ph <br /> PROGR INI ELEMENT!!!- FEE ElSurcharge FEE ❑ Other FEE <br /> INSPECTOR# ! T PERMIT VALID to ❑ Food Handler <br /> ❑ Check# A,rtOU`1T PAID Date INVOICE# <br /> ❑ Cash REVTE�rED BY ACCOUNTING OFFICE Date D b 4 <br /> . EH 0069 PINK FORM.doc I � s /fJ(J Rev.07107#99 <br />