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S v JOAQUIN COUNTY` ENVIRONMENTAL HEALTH DIVI�fON <br /> NLASTERFT-LE RECORD LNFORtiL-I.TION FORM(EH 00 69) <br /> ❑ New EH Pro am at Existing Facility New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Addressx-10�j Frain <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 required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail vlarket----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle----Make Vehicle Type Color <br /> Registration# License# Sticker n <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 /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAv1(2200) C .S �ZZQ <br /> OHazardous 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)--`lumber of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST.-I and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hote!/iti[otel-------Number of UnitsP <br /> ❑ Jail or Exempt Institution—'Number of Units <br /> Employee Housing(2700) Use Employee HousinelLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ 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/Spas at Facility El Pool El Spa C1 Out of Service PoolfSpa C1 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds C3 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 R Capacity Vehicle <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill ❑ Transfer Station C3 Ag/Cannery Waste Site C1 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 /> 11Primary Care El Acute Care 1:1 Skilled Nursing C3La Large Generator [I Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10--❑ It -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 /> PROGRA,v1ELENIENT 22-2—Q FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR#8 RC1 PERvtIT VALID . ,,A t?AoZ to CQ e— 3 i 7—°0X ❑ Food Handler <br /> ❑ Check# AIMOU`-T PAID Date INVOICE fir` <br /> ❑ Cash REVVED BY ACCOU`1T NG OFFICE `r� Date /,- <br /> Rev.07/07/99 <br /> EH 0069 P[NK FOR.M.doc <br />