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S.�` JOAQUIN COUNTY Ej RONMENTAL HEALTH DIVISI <br />'vL-kSTERFME RECORD L`iFOR-A-kTIOiy FORM (EH 00 69) <br />New EH Program at Existine Facility ❑New EH ProgDaarn and New Facility <br />I Facility ID -1-A PMO(DTl + Program Record ID Y / /�-_ _ % 1 <br />Facility Address) 410 VJ - Sat ULI if :ackN <br />(Please Check the appropriate description and specify sig number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ NO ❑ <br />C1 Commissary C3 Dry storage only 11 with Food Preparation ❑Vending Machines -Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ---Make Vehicle Type Color <br />Registration R License T Sticker <br />❑ iVlobile Food Prep Unit -Make Vehicle Type Color <br />Registration T License Sticker <br />❑ Temporary Food Facility --Dans of operation from to ❑ Ice Plant <br />❑ Special Event - Dates of operation from to ❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ iVlilk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />RAZARDOUS WASTE PROGR,bt (2200) <br />❑ Hazardous Waste Generator -------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Perrnit-By-Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST L - <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ <br />❑ HoteUNlotel-----;Number of Units Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee HousinzILahor Camp Aoplication 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 Pools/Spas at Facility Cl Pool 11 Spa C1 Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds C1 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 T License T Capacity Vehicle T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C1 Landfill C] Transfer Station ❑ Ag / Cannery Waste Site ❑ SludgelAsh 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 />C3 Primary Care ❑ Acute Care ❑ Skilled Nursing C3 Large Generator ❑Small Generator C1 Limited Hauler <br />C1 Transfer Station C1 Veterinary Clinic C] Common Storage Facility —❑ 2 - 10 C1 I - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Aoplicarion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRA.rI ELE,rIE`iT <br />INSPECTOR R <br />FEE <br />PEF.mrr VALID <br />❑ Check AMOUNT PAID <br />11 Cash REViE VFD BY (,( A jAA <br />n �!7� <br />EH 0069 PINK FORM-doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />ACCOWTING OFFICE <br />INVOICE T <br />Date <br />Rev. 07/07/99 <br />