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341 1111 JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ION <br /> ,,/ iVLASTERFILE RECORD ENFO&NIATION 1,0115,f(EH 00 69) <br /> O New EH Proat Existin Facility <br /> Facili ID q-7 —0 New EH Proctram and New Facility <br /> Facility Address80C Pro ram Record ED 05-1 -7y <br /> 5 +2ro B <br /> (Please Check the nate descnlas)CC) RonD t <br /> FOOD PROGRAM(160((600) <br /> pnoo and specify size number and Pertinent_ information.) <br /> _� <br /> ❑ Restaurant: Searing Capacity Square Footage _ <br /> ❑ Commissary ❑ Dry storage only ❑ lith Food Preparatio Food Handlers Course re°uired: <br /> ❑ Retail Market--- YES ❑ N° ❑ <br /> Square footage_ ❑Vending Machines—Number of Units <br /> ❑ Mobile Food Vehicle-- ❑ with Meat Market only ❑ 'Multiple De <br /> Make Vehicle Type p pGors ❑ Prepackaged Goods Only <br /> Registration# Color <br /> Cl Mobile Food Prep Unit--Make License# Sticker# --�— <br /> Registration# Vehicle Type <br /> License# COQ <br /> ❑ Temporary Food Facilityp Sticker# <br /> --Da[esofo operation from❑ —"—�Special Event - Dates of operation from [o to 11Ice Plant DAIRY PROGRAM(2000) 13 Produce Stand <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 PROGRAevt(2200) <br /> ❑ Hazardous Waste Generator--------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> �� ❑ Petmit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> e ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP 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 PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooLlSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C3 Poultry Farm—Maximum number of birds E3 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ 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 /> ElTransfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112- 10--C31 it -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELEMENT �.3�(] FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERhtrf VALID to ❑ Food Handler — <br /> ❑ Check# AMOUYr PAEDDate INVOICE# <br /> ❑ Cash REvrEWEDBY a COAccouNTn1GOFFICE us Date �3 <br /> Rev.07/07/99 <br /> EH 0069 PINK FOR.�I.do< <br />