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SAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI ION <br /> ML ASTERFILE RECORD 1NFORANLATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID A (3c3O o sQ Proerani Record ED <br /> FacilityAddress 6 73Z <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <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 ❑ Produce Stand <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 /> HAZARD US WASTE PROGRAM(2200) <br /> azardous Waste Generator-------------------Tons Generated Per Year G- <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 and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUiYlotel-------Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Nousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 Faciliry ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ 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 /> ❑ 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 /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator 11 Limited Hauler. <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Blue Applicadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM q <br /> CONTACT PERSON Go/ Day Ph �t3?) Ufmm tight Ph <br /> PROGRAM ELENIENT 222 0 FEE O-O O ❑Surcharge nE ❑Other FEE <br /> INSPECTOR# ?:3 7 3 PERMIT VALID �� l �O 3 toI�'l�t/ Oso ❑Food Handier_{�Q_ <br /> 11Check# Ar10 ID la l 1.t Date INVOICE# DL 1 l <br /> 13 Cash REVIEWED BY ACCOUNTING OFFICE Date 3 <br /> Rev.07/07/99 <br /> EH 0069 P[NK FORM.doc <br />