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SAM JOAQUIN COUNT ENVIRONMENTAL,HEALTH DIVPSIOO <br /> ivLASTERFILE RECORD hNFOIUMATION FORM(EH 00 69) <br /> New EH Program at Existing Faciliry ❑New EH Program and New Facility <br /> Facility ID QD 1 '� 3 Program Record ID <br /> Facility Address 6e(-Vr^A-P-j ED <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) _ <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required- YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-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 /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# 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 ClMilk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) 1- <br /> HAZARDOUS WASTE PROGRAM(2200) / TON n <br /> XHazardous Waste Generator------------------Tons Generated Per Year ` S <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(C <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 USTA and B forms - <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteVMotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Ha s7^/L by Ca o Application Form - <br /> SITE MITIGATION(2900) UNDERGROUNO INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑ Out of Service Pool/Spa ❑ Nato ral Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kenner <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> C3 Pumper Vehicle-Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) - ❑ Slud e/Ash Site <br /> 11 Landfill ❑ Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Process/Rec cle Facility ❑ CIA Landrdl Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y C1 Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> C1 Transfer Station ❑ Veterinary Clinic [I Common Storage Facility—11 60g <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHO#69 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON T L, F,) �J t C (n.l I _ Day Ph 36 g- Z 73�! Night Ph <br /> PROGRAM ELEMENT2Z 2� FEE d(..)• OL� ❑Surcharge ^EE ❑ Other FEE �� <br /> I;lSPECTOR# .g;1 -7 PERMIT VALID D Z to Z- <br /> [I Food Handler�— <br /> - ❑ Check# AMOUNT PAID Date _ INVOICE# 9 V& <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE %- <br /> Date ='� '�%"• <br /> Rev.07/07!99 <br /> EH 0069 PINK FORM.doc <br />