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S:5,-` JOAQUIN COL-LNTY E- –RO`"tiLErTAL HEALTH DIVZST`-' <br /> _� NI-ASTERFLLE RECORIJ Lv-FOR-NLATIOir FORM(EH 00 69) <br /> ,LSI N"ew•EH Program at Existing Facility ❑New EH Pro am and New Facility <br /> Facility LD PA Program Record ID G 5 �, "VI Cl <br /> FacilityAddressr(lal At <br /> (Please Check the appropriate description and specify sizes number oFunits and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C3 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES C3 No C1 <br /> El Commissary C1 Dry storage only 11 with Food Preparation ❑Vending Machines–Number of Unite <br /> C1 Retail Market—Square footage C1 with Meat Market only C3 Multiple Departments C1 Pre-packaged Goods Only <br /> C3Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration R License Sticker <br /> C3 Mobile Food Prep Unit–Make Vehicte Type Color <br /> Registration m License T Sticker <br /> ❑ Temporary Food Facility--Dates of operation from <br /> to Cl Ice Plant <br /> ❑ Special Event - Dates of operation from <br /> to C3 Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Nfulti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HLAZARDOUS WASTE PROGRAM(2300) <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)(3390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use USTA and B forms <br /> HOUSING PROGRAM(3400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HotevNlotel----:Number of Units <br /> Employee Housing(2700) Use Emplovee Hou.ybizlLahor Camp 4oalication 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 /> C1RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> C1 Abandoned HW Site ❑ non-NPL/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at FacilityClPool Cl spa <br /> C1 out of Service PooVSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Kennel <br /> ❑ Poultry Farm ,vtaximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> License Capacity Vehicle <br /> C1 Pumper Vehicle–Registration <br /> K R <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill C1 Transfer Statioa C3Ag/Cannery Waste Site 11Sludge/Ash Site <br /> ❑ ProcessfRe cle Facility ❑ CIA Landfill Site <br /> C1 Waste Tire Facility C1 Compost Facility n' <br /> ❑ Refuse Vehicles–Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> F-1 Primary Care 11 Acute Care C1 Skilled Nursing C1 Large Generator C3 Small Generator C1 Limited Hauler <br /> C1 Transfer Station C3 Veterinary Clinic C1Common Storage Facility —112- 10 ❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EN0469 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PR0CRA.N1 ELExE`iT V FEE ❑ Surcha ge FEE ❑ Other FEE <br /> LSPECOR titCVALID to ❑ Food Handler <br /> ❑ Check# A–mouN-r FAA Date INVOICE <br /> ❑ Cash RFvmvED BY D ACcouYtiti� � Date <br /> Rev.071'07199 <br /> EH 0069 PINK FORM.doc <br />