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- S JOAQUIN COUNTY vIRONMENTAL HEALTH DIVIS N <br /> D <br /> PAYMENT <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 RECEIVED <br /> ❑New EH Program at Existing Facility cw EH Program and New Facility, <br /> JUL .2 <br /> Facilit ID �3-'a� Pro ram`'Rccord ID- SAN' <br /> ACOIN COUNTY <br /> Facility Address <br /> PUBLIGOHEALTH SERVICE <br /> ENVIROWEMAL HEALTH pIVISION <br /> (Please Check the appropriate description and specify sinumber of units and pertinent information.) <br /> ze, <br /> FOOD PROGRAM(1600) <br /> 13 <br /> 0-Restaurant: Seating Capacity Square Footage Food Handlers Course re tet sired: Yl s❑ No <br /> ❑ Commissary ❑ Dry storage onl El with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage <br /> ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Toad Vehicle-----Make Vehicle Typc Color <br /> Registration If License If Sticker It <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License If Sticker If <br /> 13 Temporary Food Facility-----Dates of operation from to ❑ Tee Plant <br /> ❑ Special Event - Dates of operation ' from <br /> to 1:1 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 13 Grade A Dairy El Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Perxtut-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 fo ins <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotcl/Motel-------Number of Units ❑ Jail or Exempt institution ]`lumber of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Quin Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) // <br /> Number of Pools/Spas at Facility ElPool ❑ Spa ElOut of Service Pool/Spa 11 Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm--------Maximum number of birds 11 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License If Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer,Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Forrn <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FI:E; ❑ Surcharge FEE ❑ Other FEE <br /> INsrgcrORIf L 213 PERMIT VALID" <br /> to" 3 ❑ Food Handler <br /> aCheck# AMOUNT PAID n`�fJ r D U Date INVOICE# <br /> Cash REvt$WED BY: f' ACCOLJNIING OFFICE Date -7 <br /> f <br />