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S:kiv JOAQUIN COUi , i Y ENVIRONMENTAL HEALTH D1 vISION <br />LVIASTERFILE RECORD LNFORNLMON FORM (EH 00 69) <br />❑ New EH Pro am at Existing Facilitv & New EH Pro am and New Facility NOV 13 2001 <br />Facility ID Program Record ID <br />Facility Address /850 <br />W. Si-q,Corc� Rd. /1�4�eY, C�} <br />53 Lr�d'�I'i�.�i�•V•�'��_I�e r;rAjH <br />q 7(0 <br />PERP�1i�'s <br />(Please Check the appropriate description <br />and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity <br />Square Footage <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines —Number of Units <br />❑ Retail Nlarket ----Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Mobile Food Prep Unit --Make <br />Vehicle Type <br />Color <br />Registration # <br />License # <br />Sticker # <br />❑ Temporary Food Facility -----Dates <br />of operation from <br />to ❑ Ice Plant <br />❑ Special Event - Dates of operation <br />from to <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />U Grade Dalry i i Grade ode B LSiry ❑ N11*11: Dispense:--i':u:nber of Containers Mu!r;-Head I snit <br />CUPA � El State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />91flazardous Waste Generator -----------------------Tons Generated Per Year �QN <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />__// <br />ElPermit-By-RuleFixed Utiit C]Permit-By-RuleHousehold Hazardous Waste <br />L1d.-1BOVEGROUND STORAGE TANK FACILITY (AST) (2390) --Number of AST O� <br />UNDERGROUND STORAGE TANK (UST) PROGRANI (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/hotel------- Number of Units I ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee NnusinZlLabor Camp Application 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds ❑ 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 # 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 />❑ Transfer Station ❑ Veterivary Clinic ❑ Common Storage Facility --❑ 2 - 10 ---- ❑ it - 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIES EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Y 6AP-Y In <br />PROGRA,NI ELEMENT FEE <br />I,+sPEcroR # PERMIT VALID <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED BY <br />Day Ph ' <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date <br />EH 0069 PfNK FOR-M.doc Rev. U//Uilyy <br />