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Ask <br /> SAIN JOAQUIN COUN-17ENVIRONMENITAL HEALTH DI' I <br /> IMASTERFILE RECORD INF0MNL4,TI0N FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili II) �Y��G IS I �� ProaramRecordID <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of unite°and pertinent information.) <br /> FOOD PROGRAM(1600) . . _ --.c -_-,- - <br /> ❑ Restaurant: Searing CapacitySquare Footage _ Food Handlers Course required: YFs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines-Number of Units- -- _ — <br /> - - - <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# Sdeker# <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 ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IL,kZARDOUS WASTE PROGRAbI(2200) - <br /> f -I- azardous Waste Generator---L---z t —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)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteVL'vlotel-------Number of Units [] Jailor Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housin-/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment Cl UST-CAP Site ❑ Local BW Cleanup Site ❑ NPUSEP 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 ❑ Spa Cl Out orservice Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE_PROGRAM(4200) - - <br /> ❑ Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Tollets--Number of Units <br /> SOLID WASTE PROGRAM(4400) Cl A /Canna Waste Site ❑ SludgetAsh Site <br /> ❑ Landfill Cl Transfer Station g Cannery ❑ CIA Laadrdl Site <br /> ❑ Waste Tire Facility ❑ Compost Facility 11Process(Recycle Facility <br /> ❑ Dum sters>20 cu yd—Number of Units ClFarm/Ranch CleanuP Site <br /> 11 Refuse Vehicles—NumberofUnits P - <br /> MEDICAL WASTE PROGRAM(4500) - <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler, <br /> 11 Transfer Station ❑ Veterinary Clinic [ICommon Storage Facility—❑ '_-10—❑ 11-60—0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND16R PROGRAM - <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT2 Z?u FEE '200 ❑Surchatge�FEE ❑ Other FEE <br /> I�seeeroR# PERMIT VALID ( to (7(,3 t (p- { _ [I Food Handler <br /> _ INVOICE# %tC; <br /> ` <br /> ❑ Check# AMOUXT PAM [eft 1,�.L- Date . <br /> ❑Cash REViE1VED BY <br /> Accotmt¢+GOFFtcE <br /> Rev.07/07,99 <br /> EH 0069 PINK FORM.doc - _ _ <br />