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aid. btu ° --- 2 SAN J®AQt)IN COUNTY EN�'IR01`I1� 1~1N'TAI.HEALTH DEPARTMENT O f\ NIASTERFIL E RECORD INFORMATION FORM ❑New Eli Program at Existing Facility ❑New EH Program and New Facility '� '5//j s �/j (j Pro ram Record ID / y1 Facilrf•ID a , Facility A_ddresS _ iZd E�'�M M'� �� (Please Check the appropriate description and specify size number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yss 13 No El ❑ Commissary ❑ Dry storage only [Iwith Food Preparation ElVending Machines—Number of Units ElRetail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# El Temporary Food Facility—Dates of operation from - to 11 Ice Plant ❑ Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Bead Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑Hazardous`Waste Generator.--- Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) El Permrnit-By-Rule Fined Unit ❑Peit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/lilotel Number of Units 11 Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee dfarrsinjz= abor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30o0) ❑ EnAronmeatal Assessment ❑UST-CAP Site ❑Local IBV Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site ❑ Abandoned IfNV Site ❑ non-NPLISEP Clea-nup Site ❑RNVQCB Cleanup Site ❑ tii'ater Quality(Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ElPoultry Farm Maximum number of birds 1:1 Kennel TATTOO,BODY PIERGING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) [I pumper Vehicle—Registration# License# Capacity Vehicle# [I pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ LandfiH E] Transfer Station El Ag I Cannery Waste Site ® Sludge/Asla Site X\Vaste Tire Facility ❑ Compost Facility ❑ Process[Recycle Facility ❑ CIA.-Landfill Site ❑Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ FarmfFanch Cleanup Site filEDIGAL WASTE PROGRAM(4500) ❑ Primary Care El Acute Care ❑ Skilled Nursiag F1 Large Generator Cl Small Generator El Lin Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2- 10 ❑ 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use Pff`SE1TD�f6-02-003 BlueAppticcr6wt Fornr EMERGENCY NOTIFICATION FOR TFlis FACILITY ANOIOR PROGRAM CONTACT PERSONDay Ph Night Ph ''ll I'ROGRAMELEMENT �IuU _ FEE /" ❑ Surcharge FEE - ❑ Other FEE _ IIgSPECrOR# __1aJZ __ PERMITVALID to ❑ Faod Handler__ 1.1 Check V AmouNrF PAID ID ---- - — Date 11NOICE it — --- --- Cash !{LYiL�'1F. BY )O Accm_ dTli:,OFFICE Date -- -