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SAN 3UAQU I'i COUNTY E RONMEINTAL HEALTH DMSI <br /> hiASTERnL'E RECORD rNItORMATION FORM EH 00 69 <br /> ❑Ncw EH PrDgrarni at Existing Facility ❑New Eli Progrum and New Faacility <br /> iFittillty ID r :.PT AiiiReedrdlD <br /> Facility Address 315 S. Center Street <br /> (Please Check the appropriate description and specify Alla.number of units and oeMneent information.) <br /> FOOD PROGRAM(1600) <br /> -❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yizs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Prepaaation ❑Vtndtng Machines—Number of Unita <br /> ❑ Retail Market--Square footage ❑ with MeatMYrkct only ❑ Multiple Dcpartments D 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--r-wes ofopemtion from to ❑ Ice Plant <br /> ❑ speciRl Event - mates of operation from to © Produce Stand <br /> DAIRY PROGRAM(20M) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers.in Multi-Hea=l Unit <br /> CUP ❑ State F201ty SurrbarEe(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------------Tori Generated Per Year <br /> Tiercd Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rale Fixed Unit C] Fmnit-lay-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and S rms <br /> HG SING PROGRAM(2400) <br /> Hotti/Motel Number of Units C7 Jail or Eicmpt Institution--Number of Units <br /> rmploM Nousiur(2700)Use Enc to yet}70u 1llrhdr WgApplkad Fonn <br /> SITE lT1GAT13N(2900) UNpEgGRDLMD I4JECTIOl1 CONTROL(3000) <br /> Environmental Assessment D UST-CAP Site ❑ Local HW Cleanup Site Q NPLlSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned 11iW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site LI Water Quality Remediation Site <br /> Rff,REATIONAL HELkM PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool 0 Spa ❑ Out of Service Fool/Spa ❑ Natural l3athing tire: <br /> YECTOR CONTROL PRCWIRAM(4000) <br /> El Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BOD PIERCING PERMANENT C431MADTIC PROORAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LigulD W"—FE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# Lieense## Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic:l Toilets-----Numbs er of Units <br /> SOLID WASrlE_rR _MM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag 1 Cannery Waste Site ❑ Sludge/Ash site <br /> O Waste Tire Faculty ❑ Ctsmpost Facility ❑ Process/Retycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehiela--Number of Unite ❑ Dumpsters>20 cu yd ----Ntunber of Units ❑ Farrn/R.anch Cleanup Site <br /> MEDICAL WASTs PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator IJ Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10----❑ 11 -60--❑ >60 generarors <br /> PUBLIC WATER SYSTEM PAPGRAM(4600)Use PWS EIV0069 Blue Applicatfax Foran <br /> EMERGENCY NOTIFIGATION FOR Tins FACILITY ANUICR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PAOGRAM ELEMENT EEE ❑ Surcharge FEE ❑ Other FLE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ cseck# AMoxN'T PAID Date INVOICE# <br /> ❑ Cash REVIEWED SY ACCOUNTTNG OMCE Date <br /> EH 000 f'i?`I1C i�C1R►vl.doC <br /> Rev.0 7 ro7r1)�9 <br />