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E <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV t3iON <br /> l7ASTERFILE RECORD I\FORIVIATION FORIv1(EH 00 69) <br /> Nero at Existing Facilitv ❑New EH Pro and NewFacili t'{ Program Record I 051 <br /> FacilityAddress 2 -705 C.OLY'At4 Club Qw <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C1 Restaurant: Searing Capacity Square Footage <br /> Food Handlers Course required: Yes C1 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# Slicker# <br /> Color Type ype <br /> ❑ Mobile Food Prep Unit-Make VehicleSticker# <br /> Registration# License# <br /> to 11 Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from 13 Produce Stand <br /> C3 Special Event - Dates of operation from tO <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(2399) + , <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year ly�.l r <br /> Hazardous Waste Generator---------------— <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 TAINK(UST)PROGRAM(2300)Use UST A and 8 forms <br /> HOUSING PROGRAM(2400) <br /> 11Jail or Exempt Institution—Number of Units <br /> ❑ HoteUMotel-------Number of Units <br /> Employee Housing(2700)Use Emplavee Hopsin/LaAor Camp AppIicarion 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑ Spa [I out of Service PootlSpa [I Natural Bathing Area <br /> Number of Pools/Spas at Facility Cl Pool <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> [I Pumper Vehicle-Registration# License# P tY <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> i <br /> SOLID WASTE PROGRAM(4400) ❑ A /Cannery Waste Site ❑ SludgetAsh Site <br /> 11 Landfill C3 Transfer Station g ❑ CIA Landfill Site <br /> C3 Waste Tire Facility [3 —N <br /> Compost Facility ❑ Process/Ru Facility <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> rsing ❑ Large Generator [:1 Small Generator 11 ;imit ed Hato Sr <br /> ❑ Primary Care Ll Acute Care 13 Skilled Nu <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> C] Common Storage Facility—❑ '-- 10—❑ 11 -60—❑ 60 g <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACTPERSON <br /> T ❑SurchargeFEE ❑ Other FEE <br /> PROGRAM ELEMENT Z Z Z D FEE�� t0 31 d ❑Food Handier <br /> INSPECTOR PERMCC VAL[D -�I (U—rte DN VOICE# t`70 gS62-1I <br /> AMOUNT PAID Date <br /> [3 Check# Date, I b 0 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE <br /> Rev.07/07"99 <br /> EH 0069 PINK FORM.doc <br />