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S:_` JOAQUIN COUL TY E" ZOI.N?LENTAL HEALTH DIVISJ NL-kSTERFILE RECORL LN'FORtiL-kTIOti FOR�NI(EH 00 69) dew EH Program at Existin,Facilitv ❑New EH Progrwam and New Faciliry Facility ID NtA Lj Program Record ID FacilityAddress `a W E aK w _ ACL t!/l✓ (Please Check the appropriate description and specity sizes number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YFs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail 'vlarket—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Regiscrarion R License R Sticker R ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration T License T Sticker ❑ Temporary Food Facility--Dates ofoperarion from to ❑ Ice Plant ❑ Special Event - Dates of operarion from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Nfulti-Head Unit CUPA ❑ State Facility Surcharge(2399) FLAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Utut ❑ Permit-By-Rule Household Hazardous Waste )Z_lABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST UNDERGROnL''D STORAGE TANK(UST) PROGRAM(2300) Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution dumber of Units Employee Housing(2700) Use Emplovte Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local H-W Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-L4PL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility Cl Pool C1 Spa C1 Out of Service Pool/S ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 11 Poultry Farm Maximum number of birds C1 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration T License R Capacity Vehicle T ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill C1 Transfer Station C1 Ag/Cannery Waste Site El Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) C1 Primary Care C3 Acute Care ❑ Skilled Nursing C1 Large Generator C1 Small Generator 11 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGR t.N1 ELEXE,NT 7 X10 FEE ❑ Surcharge FEE ❑ Other FEE L`ISPECrOR# PER.wr VALID to ❑ Food Handler___ ❑ Check. A.NIOUN-I'PAID Date D4VOICE t C1 Cash REVIEWED BY '� `I �1��ACCO(M>NG OFFICE "� I Date EH 0069 Pr`"K FOR.M.doc Rev.07r07i99