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Av JOAQUIN COUN _ RONMENTAL HEALTH DI lV <br />pp NIASTERFILE RECORD INFORMATION FORM (EH 00 69) <br />New EH Program at Existing Facility ^`^ " ' __._ - -- <br />FacilitylD F�ODOV55� Program Record ED b 5 �31 G, <br />Facility Address 2-A\N `'D - <br />(Please Check the appropriate description and specify size, number of unitsand pertinent information.) <br />FOOD PROGRAM (1600) <br />S Footage Food Handlers Course required: Yrs 11 No <br />El Restaurant: Restaurant: Seating Capacity q❑Vendin Nlachines —Number of Units <br />❑ Commissary 11 Dry storage only C3 with Food Preparation g <br />❑ Retail Market ----Square footage <br />El with Meat Market only C3 Multiple Departments ❑Prepackaged Goods Only <br />Vehicle Type Color. <br />C3 Mobile Food Vehicle ----Make License # Sticker # <br />Registration # <br />C1 Mobile Food Prep Unit -Make Vehicle Type Color. License # Sticker # <br />Registraation # <br />C30 Temporary Food Facility --Dates of operation from 11 Ice Plan[ <br />L1 Produce Stand <br />❑ Special Even[ -Dates of operation from <br />to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Nlilk Dispenser—Number of Containers in Multi -Head Unit <br />COPA ❑ St a Facility Surcharge (2399) <br />aAzAR OUS WASTE PROGRAM (2200) <br />LS)'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 />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) ---Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and 8 forms <br />HOUSING PROGRAM (2400) <br />❑Jail or Exempt Institution —`lumber of Units <br />❑ HotellMotel-------Number of Units <br />Employee Housing (2700) Use EmnloVee H [< Z/Labor Camo dnnlicatlon Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />C1Environmental Assessment C3UST-CAPSite C1Local HW Cleanup Site LJNPL/SEP Cleanup Site El 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 <br />VECTOR CONTROL PROGRAM (4000) <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 />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />LIQUID WASTE PROGRAM (4200) Capacity_Vehicle # <br />[I Pumper Vehicle -Registration # License # <br />❑ Pumper Yard <br />❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Slud e/Ash Site <br />❑ Ag / Cannery Waste Site g <br />[I Landfill ❑ Transfer Station <br />[3Process/Recycle Facility ❑CIA Landfill Site <br />C3 Waste Tire Facility [I compost Facility <br />❑ Dumpsters> 20 to yd —Number of Units ❑ Farm/Ranch Cleanup Site <br />❑ Refuse Vehicles -Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />11 Skilled <br />No rsing ❑ Large Generator C3 Small Generator El Limited Hauler <br />C1 Primary Care LJ Acute Care <br />❑ Common Storage Facility --❑ 2 - t0 --- ❑ 11 - 60 --❑ > 60 generators <br />❑ Transfer Station ❑ Veterinary Clinic <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Aoolication Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/Oft PROGRAM <br />Day Ph Night Ph <br />CONTACT PERSON <br />PROGRAM ELEMENT d-�^r^� FEE _�� <br />❑ Surcharge FEE El Other FEE �— <br />to ❑ Food Handler_�� <br />INSPECTOR # �_)Z� v PERMIT VALID <br />❑Check AMOUNT PAID <br />CE # <br />"� pp�' ,�ff at INVOI_ <br />u_ex��- De <br /># <br />/_— <br />OFFICE Date '� / o <br />❑ Cash REVIEWED BY <br />ACCOUNrFNG <br />Rev. 07/07i99 <br />EH 0069 PINK FOFLM.doc <br />