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SA-` JOAQUIN COUNTY '`" ZONRENTAL HEALTH DINISIf- <br /> yl-ASTER ME REC6PD LL,FOR-NLATION FOR:N1(EH 00 69) <br /> Z_NCw EH Program at Existin, Facility ❑flew EH Pro —n and New Facility <br /> Facility ID V:�c Program Record ID /11/�- C'���' �`l <br /> Facility :address 11255 Valle-10 01, ,Wfi 011 t 491Y ,(� <br /> (Please Check the appropriate description and specify siM number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending ylachines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with,Nteat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ytobile Food Vehicle---Make Vehicle Type Color <br /> Registration R License R Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License R Sticker <br /> ❑ Temporary Food Facility--Dates 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 ❑ Milk Dispenser—Number of Containers in',Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGR.AyI(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 /> Zr_.�BOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST I <br /> UNDERGROUND STORAGE T.kNK(UST) PROGRAM(3300) Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUNtotel-----Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee Hous:rg/Lahor Camp Aoplieation Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local H`W Cleanup Site ❑ NPUSEP Cleanup Site Cl 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 C1 Pool Cl spa C3 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 T License Capacity Vehicle T <br /> ❑ Pumper Yard ❑ Package Treatment Plant Cl Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C] Landfill C1 Transfer Station C1 Ag/Cannery Waste Site ❑ SludgelAsh Site <br /> ❑ Waste Tire FaciUry ❑ 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 /> El Primary Care 11 Acute Care C3 Skilled Nursing, C3La ge Generator C1 Small Generator C1 Limited Hauler <br /> Cl Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112- 10 ❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON n //�� Day Ph Night Ph <br /> PROGRA,NI ELENLENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> LmPECTORR PEFR%J r VALID to ❑ Food Handier <br /> ❑ Checkk A.MOL'Yr PArD Date LNVOICE T <br /> C1Cish REVMVED BY ocrx <br /> 15111�� AccraJc OMca Date <br /> Rev.07r07i99 <br /> EH 0069 P(YK FOR..I.doc <br />