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As <br /> SAN JO M STERFTI E RECORD INFORM TON ORM EH 00 6D69DIVISI 1V PEC vE� <br /> ❑New EH Pro ram at Existing Facili ❑New EH Pro ram and New Facili p�0 <br /> Facilit ID DO 1A D Pro ram Record O O 6�71�LiLo AVG 5 7 `y <br /> Facility Address a Tf>7 5., 7 ce , c tam �cout s <br /> tr'� TA a ,a.. SPN 30N�PllHS�RHO\V\6\ON <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) PNO\MENSP�t+ENS <br /> FOOD PROGRAM(1600) 04\B111 <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <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# Sticker# <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 /> — <br /> CUP ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) _ <br /> ❑ Hazardous Waste Generator-----------------------Tans 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 B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700) Use Employee Hoasine/Labor Camp Application Form <br /> !b SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> A'> Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ 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 ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-----Maximum number of birds <br /> ❑ 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# Capacity Vehicle# <br /> ❑ Pumper Yard ElPackage Treatment Plant 11Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/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----112- 10-------❑ I 1 -60------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWSEH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT ';6 FEE 7i4e ) ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# t rO CI L1-1 PERMIT VALID �" t0 ❑ Food Handler <br /> Check# [t7 '9(0 PAID ( � Date INVOICE# 0 15 <br /> ., Cash REVIEWED BY ACCGUNTiNGOFFICE Date Og 3o O'D <br /> EH 0059 PINK FOP M,doc <br /> Rev.07/07/99 <br />