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i <br /> N JOAQUIN COUNTY NVIRONMENTAL HEALTH DIVIS N 3� <br /> NL1STERFILE RECORD INFORVLATION FORM(EH 00 69) 1 Fi1 3,q <br /> lH New EH Program at ExistingFacility ❑New EH Program and New Facility !t <br /> FacilityID t' ProaramRecordIDM.0,!5_6,y,_3 TA) _744,03 <br /> FacilityAddress _0-500 W L o D I hu E I Lap( <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course renuired: Yrs❑ N8 ❑ <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 Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility----Dates of operation from to ❑ Ice-Plant <br /> ❑ Special Event - Dates of operation from to ❑ Pro u ISland <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeuser—Number of Containers in Multi-Head it <br /> CUPA ❑ State Facility Surcharge(2399) s <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> G'Hazardous Waste Generator-----------------------Tons Generated Per Year -45 <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Perrait-By-Rule Hqus I Hg dour\Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)--,lumber of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and 8 forms <br /> HOUSING PROGRAM(2400) i J(�/,� <br /> ElHoteUtNiotel-------Number of Units C1 Jail or Exempt Enstitution\—Num7cr of Units <br /> Employee Housing(2700) Use Employee Hnusiu✓Labar Camp Application Form,p`1 <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000)1,/ <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEPPeanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spm 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(4121) ❑ Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Regisnation# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CL4 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 Day Ph Night Ph <br /> PROGRAAIELEMENT 717-20 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALIDto ❑ Food Handler <br /> ❑ Check# A//ir.��loun PAID Date INVOICE# <br /> ❑ Cash REVIEWEDBYVtDO P JrC-2-w tC OUNCINGOFFICE Dale p <br /> FH 0069 PINK FORM.doc y(QF5P_ bLtL Rev.07/07i99 <br />