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S AN JOAQUIN ,, UNTI ',gRON?VLENTAL HEAL : DIV _ .N <br /> NLASTERF11E RECORD C4FOR:NLATION FORM(EH 00 69) <br /> XNew EH Program at Existing Facility ❑New EH Pro am and New acility <br /> Facility LD r"', �iJ�2$ Program Record ED ' <br /> Facility Address 1014 13CS5ewle►- AiZ+iAA4 <br /> (Please Check the appropriate description and specify sizes number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course re red: YES ❑ Yo ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines LNumbe f nits <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Pr ckaged Goods Only <br /> ❑ :Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration R License# Sticker <br /> Cl Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License T Sticker <br /> ❑ Temporary Food Facility--Dates of operation from to Cl Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade?.Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> RLAZARDOUS WASTE PROGRA,tiI(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 /> ABOVEGROUND 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 /> ❑ HoteUltotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employe HousinglLahor Camp Aaplication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment [IUST-CAPSite 11 Local HW Cleanup Site C3NPL/SEP Cleanup Site C1 UIC Site <br /> Cl 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 ❑ Natural Bathing.Area <br /> VECTOR CONTROL PROGRAM(41000) <br /> C1 Poultry Farm Maximum number of birds El 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 R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill C1 Transfer Station C1 Ag/Cannery Waste Site C1 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 /> C3 Primary Care C3 Acute Care C1 Skilled Nursing C3La se Generator C1 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ l I -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Avolication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PR0GRa3t ELEr1ENT 2?AO FEE ❑ Surcharge FEE ❑ Other FEE <br /> I,+SPECrOR# 41 PERtitrr VALID to ❑ Food Handler <br /> ❑ Check R Amouvr PAID Date INVOICE m <br /> ❑ Cash REVIEWED BY ACCOU`nNG OFFICE Date <br /> EH 0069 PrNK FORM.doc Rev.OT0ir99 <br />