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S A_` JOAQUIN COCNTY ___. aRONI LENTAI. HEALTH DIVi- Y <br /> `LASTERFFLE RECORD LNFORNL-kTION FORNL I(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH=am and New Facility <br /> Facility LD FA 00 40qProgram Record ID <br /> Facility Address 4?.C) S. It1n14 LICI <br /> (Please Check the appropriate description and specify sig number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ LNo ❑ <br /> ❑ Commissary ❑ Dry storage only Cl with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail ylarket--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ ;Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration R License T Sticker <br /> ❑ ivlobile Food Prep Unit—Lkfake Vehicle Type Color <br /> Registration R License# Sticker <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to Cl 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 <br /> Tiered Permitting Facility ❑ 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) PROGRANI(3300) Use USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteU}iotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp AyOicariort Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPI-/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility C1 Pool Cl spa C1 Out of Service Pool/Spa El Yatural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm �Mmimum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C1 Tattooing(412 l) [IBody Piercing(4120) ElPermanent Cosmetics(=1122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License R Capacity Vehicle T <br /> Cl Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C3 Landfill C1Transfer Station 1:1Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> C1 Primary Care C3 Acute Care 11 Skilled Nursing C3La Large Generator C3 Small Generator C3 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ I I -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 /> PROGRAM ELEXENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR n PER.%ITT VALID to ❑ Food Handler <br /> ❑ Check R AMOUNT PAID Date 14 INVOICE# <br /> ❑ Cash REVTEwED BY 2 t-1 ACCOU`1TrNG OFFICE Date / <br /> EH 0069 PIN-K FOR.M.doe Rev.07/07i99 <br />