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a <br /> S.-kiN JOAQUIN CO -TY ENVIRONMENTAL HEALTH DIVISION <br /> NLASTERFIL RECORD INFORMATION FORM(EH 00 69) <br /> ❑ New EH Pro am at Existing Fa ility ew EH Pro am and New Facility <br /> Facility ID 00 Id-(5 Program Record ED <br /> Facility Address CrL"� <br /> (Please Check the appropriate descr' tion and specify sizes number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capaci Square Footage Food Handlers Course required: Yes ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage my ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square foo <br /> e ❑ 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 r License# Sticker <br /> C1 Temporary Food Facility-----Dates of operation from to Ice Plant <br /> ❑ Special Event - Dates of open tion 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 Surch rge(2399) <br /> HA A OUS WASTE PR GRAM(2200y � j <br /> Hazardous Waste Generator---tt-%%----------`-------Tons Generated Per Year <br /> iered Permitting F ility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STO GE TANK FACILITY(AST)(2390)--Number of AST <br /> UNDERGROUND STORA E TANK(UST)PROGRA�NI(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution dumber of Units <br /> ❑ Hotel/Motel-- ----Number of nits p <br /> Employee Housing(2700) Use Em to ee Housing/Labor Cam �I licatian 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 P OGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa C1 Natural Bathing Area <br /> VECTOR CONTROL PROG M(4000) <br /> ❑ Poultry Farm Maximu number of birds El Kennel <br /> TATTOO BODY PIERCING ERMANENT COSMETIC PROGRAM(4100) <br /> El Tattooing(412 1) ❑ Body Piercing(4120) C1 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM( 200) <br /> C1 Pumper Vehicle—Registrati n License 9 Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-----Number of Units <br /> SOLID WASTE PROGRAM( 00) <br /> ❑ Landfill ❑ Transfer Station 1:1 Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility C1Process/Recycle Facility [I CIA Landfill Site <br /> ❑ Refuse Vehicles—Number o Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRA (4500) <br /> ❑ Primary Care ❑ Ac to Care ❑ Skilled Nursing ❑ Large Generator C1 Small Generator C3 Limited Hauler <br /> ❑ Transfer Station ❑ Vet rinary Clinic ❑ Common Storage Facility —❑ 2- 10--❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM P OGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON C//? fj i(f;/tJ Day Ph 3 S'- &I /r� Night Ph <br /> PROGRAM ELEMENT `� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID �I to 13 Food Handler /_ <br /> ❑ Check# AytOU`�T PAID 1 (t1i Date INVOICE# -7Y <br /> ❑ Cash :REVIE'W"ED Y ACCOUNTING OFFICE Date <br /> EH 0069 PINK FOR.M.doc Rev.07/07/99 <br />