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SAN JOA_ <br /> COUNTY EN*� ENTAL HEALTH DEPART <br /> Existing Facility R tE RECORD INFORMATION,FORMH <br /> New EH Proeram at ExProgram and New Facility <br /> n <br /> Ulm <br /> ID rA nh) n�g(,q Program RecFFacility ord ID <br /> Facility Address 0710 LOD renis <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No 13 <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 El 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(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------El 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 USTA acid B(oris <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee Ilousing(2700) Use Employee Housin/Labor Camn Anplication 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 IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM.(3600) <br /> Dumber of Puul 'SpaS at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM.(4000) <br /> El Poultry Farm -------Maximum number of birds El Kennel <br /> TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM.(4 100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4 122) <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 ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> -Waste lire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ DUni ters>20 cu d----Number of Units ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units ti <br /> _ f� �� -- <br /> MEDICAL WASTE PROGRAM,(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility,----El 2- 10------- ❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM,(4600) Use P1VS EHD 46-02-003 Blue Avplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM, <br /> CONTACT PERSON tu� Day Ph Night Ph <br /> PI(OGIt:v>I ELENtF:NT 1-1 4 0 FEE ElSurcharge FEE ❑ Other FEE <br /> (NSPEC"IOR# 00(0c) PERMIT VALID to ❑ Food Handler <br /> O Check# AMouNT PAID <br /> Date INVOICE# <br /> 11Cash REVIEWED BY _�e 069 ACCOUNTING OFFICE /'�. Date L <br /> Masterfile Record Pink <br /> 48.0'_-034 <br /> l0/h120u3 <br />