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SAY JOAQUIN COU`' _ r NVIRONN ENTAL HEALTH DIV <br /> MASS UL RECORD INFO&VLATION FORiVI(EH 00 69) <br /> New EH Program at Existing Facility <br /> ❑Nzw EH Pro am and New Facility <br /> Facility ID FP, d .3$ Program Record ID PkoV 7 45Z- <br /> Facility Address 1200 1 <br /> (Please Check the appropriate description and specify size number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capaciry Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged <br /> C3 :tilobile Food Vehicle---Make ep ed Goods Only <br /> Vehicle Type Color <br /> Registration# License X Sticker# �— <br /> ❑ Mobile Food Prep Unit--:Make Vehicle Type <br /> Registration k Color <br /> License 9 Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to <br /> C3Special Event - Dates of operation from ❑ Ice Plant <br /> t0 C1 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> — <br /> CUP ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------_----—_Tons Generatler Year <br /> Tiered Perrnitting 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 ofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM[(2300)Use LISTA and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution—Number umber of Units <br /> Employee Housing(2 i00) Use Employee Housine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ .abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup ❑ Water <br /> Site Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <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—Registration R License R CapacityVehicle k <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfdl Site <br /> C1 Refuse Vehicles—Number of Units 11Dumpsters>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 PERSONrr�� Day Ph Night Ph <br /> PROGRAMELEVIENT P� FEE ❑Surcharge FEE 13 Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check k AMOUNT PAID <br /> [y Date INVOICE <br /> 11 Cash REVIEWED BY -p2 1A000UNiNGOFFICE Date <br /> EH 0069 PINK FORM.doc '{ Rev.07l07i99 <br />