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S A� JOAQUIN COL-NTY E:. ,RONNKENTAL HEALTH DIVISI - _ <br />.*L-kSTERFILE RECORD L`+FO-NL-kTION FORM (EH 00 69) <br />�;\'ew EH Pro�grram at Existing Faciliry ❑New EH Program and New Facility <br />Facility LD -Alf\ �(D% L'4 Program Record ED /jll� <br />FacilityAddress IVia4 %C.o- <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br />ElCommissary 11Dry storage only ❑ with Food Preparation ❑Vending iVfachines –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 />Registrarion # License �" Sticker R <br />❑ Mobile Food Prep Unit–Make Vehicle Type Color <br />Registration T License Sticker <br />❑ Temporary Food Facility --Daces 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 C1 Conditionally Authorized (CA) C1 Conditionally Exempt (CE) <br />C1rm <br />Permit -By -Rule Fixed Unit C1 Permit -By -Rule Household Hazardous Waste <br />p <br />KBOVEGROUi ID STORAGE TANK FACILITY (AST) (2390)—dumber of :QST � <br />U`iDERGROUtiD STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ Horel/Motel----Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Emylovee F(ousineyLahor Camo .laolicarion Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ .abandoned HW Site ❑ non-NPL/SE? Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ,Maximum number of birds — <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ElBody Piercing (4120) <br />❑ Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle–Registration T License T <br />❑ Pumper Yard ❑ Package Treatment Plant <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle T <br />❑ Chemical Toilets dumber of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station 11 Ag / Cannery Waste Site ❑ 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 C1 Acute Care C1 Skilled Nursing C1La se Generator ❑Small Generator ❑ Limited Hauler <br />C3 Transfer Station C1 Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ I I - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THI$ FACILITY ANO/OR PROGRAM <br />CONTACT PERSON Night Ph <br />PROCRA.I,t ELE1fEtiT FEE — <br />Lv5PECTOR # PFmwr VALID <br />❑ Check# A-NfOl,'`s�T PAID <br />❑ Cash REVIEWED BYW �Q <br />EH 0069 Pr`n FOFW.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler_ <br />Date <br />Acc=iTlNG OFFICE <br />NVOICE ryr 77 <br />Date Y <br />Rev. 077 07i 99 <br />