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SAN.IOAQUI-N COL-LNTY ' /IRONKENTAL HEALTH DIVIS NLASTERFILE RECORD lTfFORVLaTIOy FORiVI(EH 00 69) 1` New EH Program ^ at Existing Facility ❑ am New EH Progran 11 d New Facility Facility ID rA 0007'703 Program Record ED FacilityAddress (Plcye Check the appropriate description and sped size number or units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course ree aired: Yes ❑ No❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Nlachines-Number of Units ❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goads Only ❑ Mobile Food Vehicle—Make Vehicle Type Color Registration x License x Sricker x ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration x License x Sticker p ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit COPA ❑State Facility Surcharge(2399) FLAZARDOUS WASTE PROGRAM(2-700) 'Hazardous Waste Generator------------Tons Generated Per Year LS +17✓1S Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Emolovee Housine/Labor Cama Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessmear ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service PoollSpa ❑ .Natural Bathing Area VECTOR CONTROL PROGRAM(41000) ❑ Poultry Farm—Maximumnumber of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration x License x CapacityVehicle x ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ 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/Raach Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2-10—❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHO469 Blue Aoolieatfon Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRA.7t ELE,mnir �2D FEE ❑ Surcharge FEE ❑ OtherFEE 6Yseltcroitx PERMCC VALID to ❑ Food Handler_ ❑Check# AMOUNT PAM Date INVOKE- ❑Cub REvmvfED BY & 41on ACCOU`rrwa OFFICE Date EH 0069 PDOC FOR?1.doc 'Rev.07,0 7 99