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SAN JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> ivLASTERFILE RECORD LNFORNLATION FORM(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> Facili ID fes- `��� Program Record ID / E <br /> Facility Address \'�D y0 '`"� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> C1 Restaurant: Seating Capaciry Square Footage <br /> Food Handlers Course required: Yes❑ No C1 <br /> ❑ Commissary El Dry storage only C1 with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C3 Mobile Food Vehicle---Make Sticker# <br /> Registration# License <br /> Vehicle Type Color <br /> C1 Mobile Food Prep Unit—MakeVehicle # <br /> Registration# License# <br /> to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator---------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authdrized(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 /> ❑ Jail or Exempt Institution Number of Units <br /> C1 Hotenlotel-------Number of Units <br /> Employee Housing(2700)Use Employee HousiwzlLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ElUST-CAPSite ❑ Local HW Cleanup Site LlNPUSEP Cleanup Site [-I UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) (:3 out of Service Pool/Spa C3 Natural Bathing Area <br /> Number of Pools/Spas at Facility11Pool 11 Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle It <br /> ❑ Pumper Vehicle—Registration# License# <br /> ❑ Pumper Yard <br /> C1 Package Treatment Plant C3 Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ SIudge/Ash Site <br /> ❑ Landfill C1 Transfer Station 13 Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility <br /> El CIA Landfill Site <br /> C3 Waste Tire Facility [ICompost Facility C1Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units C1Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) 11 <br /> C1Primary Care El Acute Care C1 Skilled Nursing ❑ Large Generator - C3 Small Generator <br /> ier60 r—13>t60 generators <br /> ElElTransfer Station ❑ Veterinary Clinic <br /> [I Common Storage Facility —❑ '_ 10-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ❑ Surcharge FEE [3 Other FEE <br /> PROGRAM ELEMENT a � FEE ❑ Food Handler_�— <br /> INSPECTOR# PERMCr VALID ' / �' — to <br /> C3 Check# AMOU`jT PAID Date INVOICE <br /> ACCOUNTING OFFICE s ; Date <br /> C1 Cash REVIEWED BY Rev.07/07/99 <br />