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SAl`t JOAQUIN COUNTY ENVIRONKENTAI;HEALTH DIVISION <br /> ML ASTERFILE RECORD h FORMATION FO I(EH 00 69) <br /> Facility <br /> ❑New EH Pro ew EH Pro and New at Existing Facility ` - <br /> FacilityID a <br /> C) o� 3 I Program Record ED R-O 5-9: S <br /> Facility Address <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent maUon.) <br /> FOOD PROGRAM(1600) _Food Handlers Course req_ui�ed_ YFs❑ No ❑ <br /> • S uare Footage _ - <br /> ❑Restaurant: Searing Capacity - q <br /> ❑Vending Machines Number of Units <br /> ❑ Commissary C3 Dry storage only ❑ with Food Preparation <br /> C3 Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments Col❑oPrepackaged Goods Only <br /> Vehicle Type - Sticker# <br /> C1 i4lobile Food Vehicle----Make License# <br /> Registration,", Color <br /> Vehicle Type Sticker# <br /> C1 Mobile Food Prep Unit--Make License# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event -Dates of operation from <br /> DAIRY PROGRAM(2000 <br /> ❑ l�lilk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy - ❑ Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> [•LAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> ❑ Hazardous Waste Generator----------- ❑ Conditionally Exempt t(CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ permit-By-Rule Household Hazardous Waste <br /> ❑Permit-By-Rule Fixed Unit <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) ❑ Jail or Exempt Institution ,cumber of Units <br /> ❑ HotelliYlotel-------Number of Units <br /> EEmployer Ko„ti„Z/Labor Camp Apnlicat,on Form <br /> Employee Housing(2700) Use x <br /> EP <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> Site <br /> C1 Environmental Assessment [3 UST-CAP Site ❑ Local HCleanup Site <br /> W❑Cleanup RWQCB Cleanup❑Sit PSS❑ Water Quality Reme❑dtation Site <br /> ❑ abandoned HW Site ❑ non-NPI/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) (] Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility _ ❑ Pool [I Spa <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(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle#______— <br /> License# <br /> ❑ Pumper Vehicle-Registration# ❑ Chemical Toilets Number of Units <br /> ❑ Pumper-Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) 0 SludgetAsh Site <br /> ❑ Landfill ❑Transfer Station Waste Site <br /> ❑Ag/Cannery [] CIA Landfill Site <br /> [IProcess/Recycle Facility ❑ FarovItanch Cleanup Site <br /> ❑ Waste Tire Facility ❑ Compost Facility . ❑ Dumpsters>20 cu yd—Number of Units__ <br /> ❑ Refuse Vehicles-Number of Units <br /> MEDICAL WASTE PROGRAM(4500) [3Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing [3Large Generator 10❑ Common Storage Facility --❑ 2 ❑ 11-60—11>60 generators <br /> - <br /> ❑Transfer Station ❑ Veterinary Clinic - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E90069 Blue Analication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> It[Ph <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> FEE ❑Surcharge FEE <br /> PROGRA,,N1 ELEMENT -\ to - ❑Food Handler- <br /> I,tSPECTOR# _ PERMrr VALID INVOICE# <br /> A,titoU,IT PAID Date <br /> ❑Check It - ._ Date S~ <br /> 0 Cash REVIEWED BY ACCOuNMG OFFICE x.07101,99 <br />