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SAN yTOAQUTN COUNTY E ONMENTAL HEALTH DEPARTM17T <br /> MLARFILE RECORD INFORMATION FORM <br /> ($•New EH,Prograrn at Existing Faicility : Mew EH ProEM and New Facility <br /> Facility ID FA w ) 7 1..:`- Program Record ID OSee' 31-0 <br /> Facility Address0l5 6� S• S� <br /> (Please Check the appropriate description and specify jim number of units and pertinent Informer ion.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating CapacitySquare Footage Food Handlers:Colo se required: YES 13 No❑ <br /> ❑ Commissary ❑Dry storage only ❑with Food Preparation . Mending Machines.—Number'of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple::0 p*fnfeats. ❑Prcpackaged 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 ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy ❑Grade B Dairy ❑Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUP A ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑Hazardous Waste Generator Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit O Permit-By-Rule Household Ilazardous Waste . <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B towns <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel Number of Units 1❑Jail or Exempt Institution dumber of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Caine Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site 0 NPLJSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HW Site ❑non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water 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# License# Capacity Vehicle# <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 /> fffVaste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site <br /> ❑Refuse Vehicles.Number of Units ❑Dumpsters>20 ca 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 PIVSEHD 46-02-003 BlueApplieatlon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACTPERSON y� Day Ph Night Ph <br /> PROGRAM ELEMENT 1Lf-0 FEE iv ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 't-f02J'S PERMITVALII) to ❑.Food Handler <br /> ❑Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY Accovrn NG OFFICE Date <br />