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9A`1 JOAQUIN COUNTY ENVIRONII�IENTAL HEALTH DIVISION <br /> 11ASTERFII E RECORD T`IFORbL4TION FOP (EH 00 69) <br /> ❑ New EH Program at Existing Facility txew EH Program and New Facility <br /> Facility ID001 (� Program Record ID 7 1 <br /> Facility Address 45- � N J <br /> (Please Check the appropriate description and specify size-number of units and pertinent information.) - <br /> FOOD PROGRAM(1600) 11 - <br /> ❑ Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YFs❑ No❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Nlobile Food Vehicle—Make Vehicle Type - Color <br /> Registration# License# Sricker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type - Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operarion from to ❑ Ice Plant <br /> ❑ Special Event - Dates 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 /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARD S WASTE PROGRAM(22 t ZO <br /> azardous 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) PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUpvlotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Ho rr' glLahor Cama Application Farm <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site Cl 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/Spa-s at Facility Cl Pool 11 Spa El Out of Service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11 Tattooing(412 1) El Body Piercing(4120) 1:1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - - <br /> C1 Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> t <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill [I Transfer Station ❑Ag/Cannery Waste Site 11 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 /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler, <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility —112- 10—❑ it -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Ancficarion Form - <br /> EMERGENCY NOTIFICATION FORTHis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON �,..00 Day Ph Night Ph <br /> PROGRAM ELE(p�($<N'TI ZZU FEE v`'� ❑.Surcharge-F,ErE ❑ Other FEE _�— <br /> IC[SPECroR# p 1 PERMIT VALID <br /> io �� f ❑FoodHandler�� <br /> ❑ Check# AMotMPAID a[e f6�c�(.- - INVOICE# <br /> ❑ Cuh REVIEWED BY ACt1otlNradG DFFIIE - ' "Date <br /> Rev.07107i99 <br /> EH 0069 PINK FORM.doc <br />