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And <br /> SAN JOP,QUIN COUNTY'ENVIRONMENTAL HEALTH DIVI N <br /> MASTERME RECORD INFORMATION FORM(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Pro am and New Facility <br /> Facili ID Program Record ID X 0,1� {. <br /> FacilityAddress EW✓i N1W <br /> (Please Check the appropriate description and specify sizem num er of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yes C1 No 11 <br /> ❑ Commissary ElDry storage only C1with Food Preparation ❑Vendi¢g Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color T <br /> Type❑ Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License# <br /> Color <br /> T <br /> Type El Mobile Food Prep Unit—Make VehicleSticker# <br /> Registration# License# <br /> to 11 Ice Plan[ <br /> C3 Temporary Food Facility--Dates of operation from 11produce Stand <br /> ❑ Special Event - Dates of operation from to <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 /> FLkz,yKDOUS WASTE PROGRAM(2200) G �L4V�vg4 <br /> Hazardous Waste Generator-------------- --Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Per¢rit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use F lavee Ho cin/Lahor Ca,O Aoolicarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment C1 UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool El Spa <br /> C1 out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) C3 Permanent Cosmetics(4122) <br /> C1 Tattooing(412 1) 11 Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> C3 Pumper Vehicle—Registration# License <br /> [I Package Treatment Plant 1:1 Chemical Toilets—Number of Units <br /> ❑ Pumper Yard - _ <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> C1 Landfill El Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recyde Facility <br /> ❑ CIA Landfill Site <br /> C3 Waste Tire Facility ❑ Compost Facility 0 Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 to yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator or ❑ Small❑Generator 0 Limited <br /> generators <br /> ❑ Transfer Station ❑ Veterinary Clinic [I Common Storage Facility —❑ 2- 10-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> 13 FEE <br /> FEE ❑ Other FEE <br /> PROGRAM ELEML,NT FEE_ to ❑ Food Handler <br /> INSPECTOR# PERMrr VALID y <br /> Date INVOICE <br /> ElCheck# AMOUNT PAID �-- <br /> Date <br /> ACCOUNTING OFFICE <br /> El Cash REylt�vED UY Rev.07/07199 <br />