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SA:,N JOAQUIN COU'LNTY - rIRONMEtiT:-L HEALTH DIVIF v NL-,STERFELE RECORD LYFORINLATION FOR:NI (EH 00 69) .� New EH Program at Existio, Facility ❑New EH Pro am and New Facility Facility ID v.7A DM47 g� Program Record ID Facility Address 1 IDI 1 ea5--t- thnJ (Please Check the appropriate description and specify number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ :Mobile Food Vehicle ---Make Registration R ❑ Mobile Food Prep Unit --Make Registration T ❑ Temporary Food Facility --Dares of operation ❑ Special Event - Dares of operation from DAIRY PROGRAM (2000) Vehicle Type Food Handlers Course required: YEs ❑ No ❑ ❑Vending Machines —Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only License R Vehicle Type License T from to to _ Color Sticker _ Color Sticker # ❑ Ice Plant ❑ Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in ivtulti-Head Unit CUPA ❑ State Facility Surcharge (2399) ELAZARDOUS WASTE PROGRa,*vi (2200) ❑ Hazardous Waste Generator ------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste IM ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST 2 UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) ❑ Hote0,lotel------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housine/Lahor Camp rloplication Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) 1:1 Environmental Assessment 11 UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ oon-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility Cl Pool Cl spa C1 Out of Service Pool/Spa C1 .Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle—Registration T _ ❑ Pumper Yard License ❑ Package Treatment Plant ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle T ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM (4400) C1 Landfill C1 Transfer Station C1 Ag / Cannery Waste Site 1:1 Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) 1:1 Primary Care C3 Acute Care ❑ Skilled Nursing ElLa Large Generator C1 Small Generator 11 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ 11 - 60 —❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON PROGRA.N1 ELEE`iT 2 D yIFEE — IVSPECTOR # t PERmrf VALID ❑ Check k A -MOUNT PAID 11Cash RW EVIEED B & I M EH 0069 PINY. FOR.M.doc Day Ph ❑ Surcharge FEE to Date ACCOU`tTtNG OFFICE — Night Ph ❑ Other FEE ❑ Food Handler INVOICE T Date Rev.07/07i99