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S— JOAQUIN COU T1 IIRONI:IIET'TAL HEALTH DIVi I <br /> NLASTERFELE RECORD LYFORtiL-kTION F. ,RtiI(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Pro am and New Facility <br /> Facilitv LDCA A DCOq ZS 5 Program Record ID <br /> Facility Address ?092 yQX1t7,tS �(.!Z mas,�,+cCO <br /> (Please Check the appropriate description and specify sizes number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br /> ElCommissary ElDry storage only 11with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail iVlarket---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ;Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration T License R Sticker T <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration T License T Sticker L <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-By-Rule Household Hazardous Waste <br /> A ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--Number of AST �— <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/}Iotel-------Number of Units ❑ Jail or Exempt Institution `umber of Units <br /> Employee Housing(2700) Use Emplovee Housing/Labor 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 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 13 Pool C1 Spa C1 Out of Service Pool/ <br /> C3 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 /> C1 Tattooing(412 1) El Body Piercing(4120) C3 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration T License K Capacity Vehicle R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill ❑ Transfer Station El Ag/Cannery Waste Site 1:1 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 C1 Acute Care C3 Skilled Nursing C1 Large Generator C3 Small Generator C3 Limited Hauler <br /> Cl 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 Day Ph Night Ph <br /> PROGR km ELEMENT 23eD FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR$ PER.titrr VALID to ❑ Food Handler <br /> ❑ Check AMOUNT PAID Date INVOICE Or <br /> ❑ Cash REVIEWED BY o9.-a-2CG0 ACCOU"I`t G OFFICE Date <br /> EH 0069 PINK FOR.%t.doc Rev.07/07/99 <br />