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S.kN JOAQUIN COUNTY F -RONILENTAL HEALTH DIVISI NLaSTERFELE RECORD E FORvLATION FORA(EH 00 69) ) —j New EH Program at Existine Facilicv ❑New EH Pro am and New Facility 'A ,� ' Facility ID A 00 IProQram Record ID h� Sam FacilityAddress -�1A)C0J w&,r-& Avec ai ,MCal (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ 11Commissary 11Dry storage only C1with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market--Square footage ❑ with ivleat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration n License R Sticker ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration T License R Sticker ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dares of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-------------------Tori Generated Per Year Tiered Permitting Facility C1 Conditionally Authorized(CA) C1 Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(3390)—Number of AST L_ UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms HOUSING PROGRAM(2400) ❑ Hotei/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing(2700) Use Employee HousinzILabor Camp Ai7plication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa C3 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) C3 Poultry Farm Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) C3Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License Capacity Vehicle R ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) C] Landfill C1 Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—dumber of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care C1 Skilled Nursing C1La Large Generator C1 Small Generator C3 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEZNIE`1T FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR$ PER%IR VALID to ❑ Food Handler ❑ Check# AIMOINr PAID Date INVOICE T C3 Cash REVIEWED BY AccotrvTlarc 0 [ca Date Rev.07107i 99 EH 0069 PINKFOR.�t.doc