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SAS JOAQUI`1 COUNTRONAIE`tTAL HEALTH DI N <br /> NLASTERFILE RECORD LNFOR:NLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility 2 ❑New E Pro and New Facility <br /> Facility IDEA 371OProaram Record ID <br /> Zelb <br /> Facility Address Allo N. YW <br /> (Please Check the appropriate description and specify size, n tuber of units and Dertinent information.) <br /> FOOD PROGRAM(1600) <br /> C1q <br /> Restaurant: Searing Capacity Square Footage Food Handlers Course required: <br /> YFs 11 No C1 <br /> ❑ Commissary ❑ Dry storage only ❑ 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 m License R Sticker R <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration 4 License 9 Sticker r <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 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-lay-Rule Household Hazardous Waste <br /> bi'ABOVFGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Niotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2 MO) Use Employee Hous) ?/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> C1 Abandoned HW Site C1 non-NPL/SEP Cleanup Site C1RWQCB Cleanup Site 11 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility L1Pool El spa 11 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration <br /> License» Capacity Vehicle` <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ElSludgelAsh Site <br /> C3 Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility ❑ CIA Land£dl Site <br /> ❑ Waste Tire Facility C1 Compost Facility ❑ Farm/Ranch Cleanup Site <br /> C1 Refuse Vehicles—Number of Units ❑ Dumpsrers>20 cu yd —Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> Cl Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2. 10—❑ 11 -60—Q>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Aoplfcatiort Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON n Day Ph Night Ph <br /> PROGRAM ELEMENT` FEE El Surcharge FEE Other FEE <br /> ISsPEC .�rORPEPMrr VALID to ❑ Food Handler_ <br /> ❑ ch<ckK <br /> AMOUNT PAID Date INVOICE R <br /> Date <br /> C1 cash REViEtivED BY <br /> 2_I�..O ACCOUNTINr OFFICE <br /> Rev.07I07i99 <br /> EH 0069 PINK FOP-M.doc <br />