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S.kN JOAQUIN COI1iiT1 TIRONNLENTAL HEALTH DIVVW <br /> NLASTERFLLE RECORD LNFORtiLA.ION FOR. ,[(EH 00 69) <br /> ;RDN. ew EH Program at Existing Facility C3 New EH Progartl and New Facility <br /> Facility LD FA DD105 3� Program Record ED <br /> Facility Address 1500 P. AA0,A & <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 /> C3Commissary C3Dry storage only Elwith Food Preparation []Vending Ylachines—`cumber of Units <br /> Cl Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ;Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration R License R Sticker <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration T License R Sticker <br /> ❑ Temporary Food Facility--Dates 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—`cumber of Containers in Mufti-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2300) <br /> Cl 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 /> NQNBOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST I <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emplovee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 El Spa C3Out 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) 11 Body Piercing(4120) C3 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Cl Pumper Vehicle—Registration T License T Capacity Vehicle T <br /> ❑ Pumper Yard C] Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill ❑ Transfer Station C1 Ag/Cannery Waste Site ❑ SludgelAsh Site <br /> ❑ Waste Tire Facility (:1 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 /> C3Primary Care C3 Acute Care ❑ Skilled Nursing C3 Large Generator ❑ Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ It -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA.Nt ELEMENT I- Q FEE C3 Surcharge FEE ❑ Other FEE <br /> IPISPECrOR R PERNIrr VALID to ❑ Food Handler <br /> ❑ Check R Amon-r PAm Date L`IVOICE r'r <br /> ❑ Cash REVIEWED BY 044AZ I( CD ACCOUNTING OMCE Date <br /> Rev.07/07199 <br /> EH 0069 PfYK FOR-M.doc <br />