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SA!� JOAQUIN COUNTY E- RO ILENTAL HEALTH DIVISIr <br /> :',LASTERFII E RECORL uv-FORtiL-kTION FORM(EH 00 69) <br /> EH Program at Existing Facility ❑New EH Pro -rn and New Facility <br /> Facility ID V 00 9 J Program Record ID P U S 161 1"I <br /> Facility Address �rJ�Z M2 SS l/1/GZ.V , eSC JM/L — tk)fiQh f7 1�,fk*[,c,K <br /> (Please Check the appropriate description and specify siM number 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 Un;cs <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 R Sticker a <br /> ❑ liobile Food Prep Unit-Make Vehicle Type Color <br /> Rem stration T License Sticker <br /> ❑ Temporary Food Facility--Dates of operation from Co— Cl Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> Cl Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> RAZARDOUS WASTE PROGRA,rI(2200) <br /> ❑ Hazardous Waste Generator------------------Tons Generated Per Year <br /> Tiered Permitting Facility C1 Conditionally Authorized(CA) C1 Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pear it-B 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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hote0,lotel----Number of Untl:s ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Emalovee Housing/Labor Camo rloplicariort Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HSV Cleanup Site ❑ NPLJSEP 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/Spas at Facility Cl Pool Cl spa C1 Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C] Poultry Farm Maximum number of birds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C1 Pumper Vehicle-Registration T License#, Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill C3 Transfer Station C1Ag/Cannery Waste Site El 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 /> Cl Primary Care C1 Acute Care ❑ Skilled Nursing C1 Large Generator C1 Small Generator C1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—112- 10 C111 -60—13>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Avolication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRA,Nt ELENMNT -J'1 V FEE ❑ Surcharge FEE ❑ Other FEE <br /> LY$PECTOR# PEP-mrf VALID to ❑ Food Handler__ <br /> ❑ Chcck# A:MOtr,rr PAID Date INVOICE it <br /> ❑ Cash REvicwED BY bo ACCOUvr>rG OFFICE Date / <br /> Rev.07707799 <br /> EH 0469 Pr`"K FOP-M.doc <br />