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S:_,N JOAQUIN COUNT`` iVIRONNIENTAL HEA -LTH DIVT N <br />/ IvLASTERFILE RECORD L`iFOR-tiLkTIO`i FOFLN1(EH 00 69) <br />LX`'ew EH Program at Existing Facility ❑New EH Program and New Facility <br />1 Facility LD : F A— 0 0 1 (A *4-(0 Program Record ED f�R P 502�l 53 1 <br />Facility Address k"kL-&:&e Z -i `1) i <br />(Please Check the appropriate description and specify si. ie number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YFs ❑ No ❑ <br />13Commissary C3Dry storage only C3with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market --Square footage ❑ with �14eat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ :Mobile Food Vehicle ---Make <br />Registration R <br />❑ Mobile Food Prep Unit—Make <br />Registration <br />❑ Temporary Food Facility --Dates of operation <br />❑ Special Event - Dares of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Vehicle Type <br />License R <br />Vehicle Type <br />License T <br />from to <br />to <br />_ Color <br />Sticker <br />_ Color <br />Sticker T <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAbI (2200) <br />❑ Hazardous Waste Generator -------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule FL -ed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />`E1 ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST,4 and B forms <br />HOUSING PROGRAM (2400) <br />❑Jail or Exempt Institution Number of Units <br />C1Hotel/i`lotel------- Number of Units P <br />Employee Housing (2700) Use Employee HousinglLahor Camp—oolication Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HSV 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 C1 Spa C1 Out of Service Pool/Spa C1 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm �tMaximum 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—Registration T - <br />C1 Pumper Yard <br />License R <br />❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle <br />❑ Chemical ToiletsNumber of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill C3 Transfer Station C1 Ag / Cannery Waste Site C3 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 —dumber of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />1:1Primary Care ❑ Acute Care C1 Skilled Nursing C1La be Generator C1 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 ADolication Form <br />EMERGENCY NOT10ICATION FOR THIS FACILITY ANO/OR PROGRAM <br />CONTACT PERSON <br />PROGRA.rt ELEXENT_33 `t° FEE _ <br />I;vsPECTOR V PERMIT VALID <br />❑ Check # AMOUNT PAID <br />❑ Cash REVIEWED BY 414 / �t L (4 <br />EH 0069 PDrK. FOR.M.doc <br />Day Ph <br />Night Ph <br />❑ Surcharge FEE ❑ Other FEE <br />to <br />Date <br />..kCC0 Nr1NG OFFICE <br />❑ Food Handler <br />INVOICE T — <br />Date 3 <br />Rev. 07/07/99 <br />