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AL <br /> SAKI JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DTVI iON <br /> MASTERFILE RECORD l31F0R1'yLkTI0N FORNI(EH 00 69) - <br /> O/New EH Program at Existing Facility ❑New EH Program and New FacilityM. /3//0 <br /> Facility ID co I t T3 Program Record ID 0 9 <br /> FacilityAddress 6176V Al-/c GT <br /> (Please Check the appropriate description and specify size•number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing CapacitySquare Footage Food Handlers Course required: YEs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ RetaiI 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 11 Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Lf <br /> CT'Hazardous Waste Generator--------- <br /> <- 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 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 Housin- ahor 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 PooWSpas 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—Registradon# 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 ❑ FarmIRnnch 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—112- 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�MELEMENT MO a FEE ❑.SurchargejF 7E ❑Other FEE - <br /> INSPECTOR# 8375 PERMIT VALID T ❑Food Handler <br /> ❑Check# AMOUNT PAID 0 Date INVOICE# —_ <br /> El cash REvrmw BY ACCOUNMG OFFICE Date <br /> EH 0069 PINK FORM.doc /Ylooec® w /213r Z Rev.07/07/99 <br />