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SAL JOA.QUIN COUNV'ENVIRON IIVIENTAti HEALTH DIV ON <br /> MASTERFILE RECORD I Vi FORIINLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Fi-cility— <br /> FacilitY ID 06 00 3 Program Record EDD 5 7 7 <br /> Facility Address C 33 E. V kj r RD. <br /> (Please Check the appropriate description and specify size'number of units and pertinent information.) <br /> FOOD PROGRAM(1600) - - - <br /> El Seating Capacity _ Square Footage Food Handlers Course required: YEs❑ No D <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 /> , <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color Sticker# <br /> Registration# License# <br /> to ❑ Ice Plant <br /> ❑ Temporary Food Facility---Dates of operation from ❑ produce Stand <br /> C1 Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) O S L Y' <br /> XHazardous 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)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A andB forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C1 HoteUtYfotel-------Number of Units <br /> Employee Housing(2700) Use Em loyee HottsinelLabor Camp Application Form, <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1W UST-CAP Site ❑ Local HCleanup Site 11 NPI 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) ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool 11 Spa [I Out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCINGt PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# Capacity <br /> ❑ Pumper-Yard. 11 Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) [3 Sludge/Ash e/Ash Site <br /> 11 Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site g <br /> ❑ Process/Recy cle Facility ❑ CIA Landfill Site <br /> 11 Waste Tire Facility ❑ Compost Facility 0 FarmlRanch Cleanup Site <br /> C1 Refuse Vehicles—Number of Units El Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 11 Acute Care ❑Skilled Nursing 13 Large Generator [1 Small Generator ❑ ;imit nH Hauler <br /> ols <br /> 11 Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility- ❑ 2- 10 ❑ 11 -60—❑ 60 g <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 /> 27,U FEE Zbo` 00 ❑Surcharge FkE ❑ Other FEE <br /> pROGRAt1Q ELEhiENT�}2 to /a ❑ Food Handler �I <br /> I;VSPECTOR# 3 t PERMIT VALID f�!�D OOGI/ S1 7 <br /> ❑ Check# kNIOU`1T PAID Date INVOICE# — <br /> AccouNrtNc OFFICE Date <br /> [3Cash REv[EwED BY --_R_07/07/99 <br /> EH 0069 PINK FORM.doc <br />