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S:--N JOAQ-�iIV COUNTY E.N- V,.,J`-N EYT.A.L HEALTH DIVISIOi 1� <br /> 'vLASTERFU E RECORD L`I-FORVLAXIO FORM(EH 00 69) <br /> Neu, EH Pro ar�Existing FacnniliN ❑New EH Pro m and New Facility0M <br /> Facility ID VR C (L I Prol'ram Record ID i i�c. <br /> Facility Address 95MO <br /> (Please Check the appropriate description and specify sizenumber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ 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# Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration p License T Sticker m <br /> ❑ Temporary Food Facility—Dates of operation from to C3 Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Staod <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State FacilitySurcharge(2399) <br /> FUAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permic-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> P�aBOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300) Use USTA and 8(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel---:Number of Umu ❑ Jail or Exempt Institution—Number of Units <br /> Employee Hourin%(2700) Use Employee No s' =/Labor Camp Aoo1icarian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> Cl Environmental Assessment 11UST-CAFSite ❑ Local HW Cleanup Site C3NPIUSEP Cleanup Site Cl UIC Site <br /> Cl .Abandoned HW Site ❑ oon-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility C1 Poo( ❑ Spa Cl Out of Service Poouspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(=000) <br /> 11 Poultry Farm—Maximum number ofbirds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle—Registration+ License Capacity <br /> Cl <br /> Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Ststioa ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CLk Landt-dI Site <br /> Cl Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—❑ It -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAbI ELEOIEhT alto FEE ❑ Surcharge FEE ❑ Other FEE <br /> LVSPECTOR# PERMIT VALID to ❑ Food Handler. <br /> ❑ Check# AmomiT PAID Date INVOICE T <br /> ❑ Cash REVrE EO B ACCOUN NG OFFICE Dace . <br /> C . <br /> - 'Rev.0V07i99 <br /> EH C469 PN-K FO(LMAcc <br />