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r ' <br /> 4 <br /> SA.N JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> NIASTERFILE RECORD LNFORINL4TION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility Ncw EH Program and New Facility <br /> Facility ID Ob 7 Program Record ID 0 <br /> Facility Address Y 3 M D 94 4- a 1 LSA. , -A4 4,cj �Q CA <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) -Aq <br /> ❑ Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Ylachines-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 R <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(3399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator-------- Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Uait ❑ 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 /> ❑ Hotenjotel---Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee HousinglLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> dumber of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooVSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ 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 ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑rig/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 Unit ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care C1 Acute Care ❑Skilled nursing 11 Urge Generator ❑ Small Generator [I Limited Hauler. <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2.10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON '4^ Day 1 Day Ph �l Z 3' 71 � <br /> 2 1 Night Ph <br /> PROGRA,VIELEhfENT FEEgo <br /> �J ❑Surcha E ❑Other FEE <br /> IdSFECTOR# 3 'PERMrrVALID // - to /L j O. :- - ❑FoodHan'dler_ <br /> 11 Check AMOUNT PAID "Date /`�-'ID3: 'INVOICE# •/ <br /> ❑ Cash REVIEWED BY ACCOtMCtNG OFFICE Date <br /> Rw 07/0759 <br />