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SAN JO AQUIN COL-NTY - rIROr-i�,LENTAL HEALTH DIVISW <br />tiLASTERFELE RECORD D'FORNLATIO"N FOR -NI (EH 00 69) <br />lS ;I`ew EH Program att Existing FFaciilli-tty ❑New EH Pro am a d `!ew Facility <br />Facility ID FA0oD�� Program Record ED 61 Llaii55 I <br />Facility Address 0145 N - U,V9X, k()C(.C.{, NlU-,LLT _ !1,X <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 />11 Commissary C3 Dry storage only C3 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 # License T Sticker <br />C1 Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration T License R Sticker <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 />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />M,�BOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST 1_ <br />UrDERGROUND STORAGE T .NK (UST) PROGRAM (2300) Use UST A and 8 forms <br />HOUSING PROGRAM (2400) <br />❑ HoteUMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emplovee Housi-tol ahor Camp rloplication 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 Cl Spa ❑ Out of Service Pool/Spa Cl Natural Bathing Area <br />VECTOR CONTROL PROGRAM ("000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registrarion T _ <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License m <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle R <br />C1Chemical Toilets Number of Units <br />❑ Landfill Cl Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <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 />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON I Day Ph Night Ph <br />PROGRA.Vt ELENIE` T a3RQ FEE_ <br />IN <br />EE— <br />I, rSPECTOR X PEFWrT VALID <br />❑ Check n A.140n-r PAID <br />❑ Cash REVMVEcD BY QNB. <br />EH 0069 Pr." K FOFLM.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler—� <br />Date <br />ACCOUYI INC; OFFICE <br />INVOICE u <br />Date <br />Rev. 07i07i 99 <br />