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SA1N JOAQIfIN COUNTY TY ENVIRONMENTAL HEALTH DMSION <br /> IMA$TERFILE RECORD LNF0ILNLATI01N FORM(EH 00 69) <br /> New EH Program at xisting acility ❑New EH Program and New Facility <br /> Facility ID D 1 3 Program Record ED 3 <br /> Facility Address b 11 NVA- <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(16 0) <br /> ❑ Restaurant: Sea ng Capac ry Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ElCommissary C1ry storag only 11with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market--S uare foot ge ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C1 Mobile Food Vehicl Mak Vehicle Type Color <br /> Re;istration License R Sticker# <br /> ❑ Mobile Food Prep nit--Mak Vehicle Type Color <br /> Re stration License# Sticker# <br /> ❑ Temporary Food F cility— Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Da es of ope tion from to C3 Produce Stand <br /> DAIRY PROGRAM (2 00) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Faci ity Surch rge(2399) <br /> I-LAZARDOUS W STE PR GRAM(2200) TtJ�s <br /> AHazardo s Waste Generator---------- ----Tori Generated Per Year <br /> Tiered Per 'tting F cility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGRO ND STO GE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUN STORA E TANK(UST)PROGRAivI(2300)Use UST A and B forms <br /> HOUSING PROGRA (2400) <br /> ❑ Jailor Exempt Institution Number of Units <br /> ❑ Hotel/Motel------N mber of nits <br /> Employee Housing(2700 Use Em to ee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2 00) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Ass ssment C1 UST-CAP Site ❑ Local HW Cleanup Site 11NPLJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Si e ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site 4' ❑ Water Quality Remediation Site <br /> RECREATIONAL HE LTH P GRAM(3600) <br /> Number of Pools/Spas a Facility C1 Pool ❑ Spa C1 Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL ROGRA (4000) <br /> C1 Kennel <br /> ❑ Poultry Farm Maximu number of birds <br /> . <br /> TATTOO BODY PIE CING ERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PRO GRAM(4 00) Vehicle <br /> ❑ Pumper Vehicle—R gistratio # License# Capacity <br /> t ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PRO RAM(44 0) ❑ Sludge/Ash e/Ash Site <br /> C1 Landfill C1ransfer Station C1 Ag/Cannery Waste Site g <br /> ❑ Process/Re cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ ompost Facility Process/Recycle ❑ Farm/Ranch Cleanup Site <br /> C1Refuse Vehicles—t umber of nits ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE P OGRAM(4500) <br /> C1 Primary Care ❑ Acut Care C1 Skilled Nursing 11 Large Generator C1 Small Generator C1 Limited Hauler <br /> ❑ Transfer Station ❑ Vete 'nary Clinic ❑ Common Storage Facility—❑ 2-10 ❑ 1 l -60—❑>60 generators <br /> PUBLIC WATER SY TEM PR GRAM(4600)Use PWS E 70069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph ��,�—S7 LL Night Ph <br /> PROGRAim ELEN E FEE , 6 L ❑Surcha FEE ❑ Other FEE <br /> N <br /> INSPECTOR# l PERMIT VALID to Z ❑ Food Handler <br /> ❑ Check# til01M PAID Date INVOICE# ` <br /> ❑ Cash vED BY At a)utrrlrtG OFFICE Date <br /> Rev.07/07/99 <br />