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S:k\ JOAQUI`( COUNTY E RONME`iTAL HEALTH DIVISI.� <br /> VLASTER.FME RECO YFOR-NLATION FORM(EH 00 69) <br /> ONew EH Program at Existine Facility ❑New EH Pro m and New.facility <br /> Facility ID FA GO 10 EA D Program Record ID <br /> Facility Address I LO I E. Trwvis 2 K 0.f�D <br /> (Please Check the appropriate description and speciry size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant. Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary Cl Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑ with bleat Market only ❑ Multiple Depar rrients ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration: License p Sticker <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration T License m Sticker <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Daces of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> ILAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------------Tons Generated Per Year <br /> Tiered Perrnitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) _ <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-fay-Rule Household Hazardous Waste <br /> ,ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST _ <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use USTA and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hatet/Motel-----—Number of Units ❑ Jail or Exempt Institution—`lumber of Units <br /> Employee Housing(2700) Use Eylovee Housin,/Labor Camp.loplication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Sps at Facility ❑ Pool ❑ Spa Cl Out of Service Pool/Spa ❑ :Natural Bathing.Area <br /> VECTOR CONTROL PROGRAM(:000) <br /> ❑ Poultry Farm—Maximum number ofbirds ❑ fennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Regisnarion T License m CapacityVehicle m <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4300) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Cl 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 /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—❑ 11 -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 2/� Day Ph Night Ph <br /> PROGRAM ELEMENT /J 3ID FEE 13 Surcharge FEE ❑ Other FEE _ <br /> L`tSPECTOR# PERMrr VALID to ❑ Food Handler_ <br /> ❑ Check: A.Mon-T PAID Date INVOICE m <br /> ❑ Cash REvrEwEtl BY06 4 2D DG) ACCOUN 1NG OFFICE Date <br /> Rev.07i07i99 <br /> EH 0069 PI\iC FORbt.doc <br />