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�IRONMENTAL HEALTH DTVISI�i <br /> SAN JOAQU�N COUNTY I • <br /> IMASTERFILE RECORD LNFOR;�IATION FORsri(EH do 69) ��� <br /> ❑New EH Pro i e <br /> Program and w Facility 1 • 1 'A , , (q <br /> ❑New EH Pro at ExistingFacility '-'i <br /> Facili IDA0b0 c) fl(Z <br /> Program <br /> Record <br /> Facility Address 0j mel <br /> f&—m <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: YES❑ No <br /> [3 Restaurant-. Seating Capacity Square B ❑Vendin Machines--Number of Units <br /> C3 Commissary 13 Dry storage only ❑ with Food Preparation g <br /> ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C3 Retail Market----Square footage 13 with Meat Market only <br /> C1 Mobile Type Color Mobile Food Vehicle-----Make Sticker# <br /> Registration# License# <br /> Color <br /> T <br /> ype <br /> ❑ Mobile Food Prep Unit--Make VehicleSticker# <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C3 Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator ----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pertrdt-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> P.aBOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST­��--- <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and 11 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> ❑ HoteUlvIatel-------Number of Units <br /> Employee Housing(2700) Use Em fo ee Housin/Labor Como Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UTC 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 Facility 11 Pool El Spa C1 Out of Service Pool/Spa [3 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds C3 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 /> [3 Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill C3 Transfer Station C3 Ag/Cannery Waste Site 11 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 /> 1:1 Primary Care C3 Acute Care ❑ Skilled Nursing 11 Large Generator C3 small Generator [3 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----❑ 2- 10------❑ 11 -60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Applicatioll Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 23 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERIvI1T VALID to ❑ Food Handler <br /> ❑ Check# A�,MOUNT PAID Date INVOICE# <br /> ❑ Cash REVtEWE:D BY ACCOUNTING OFFICE Date ' 1 <br /> EH 0069 PIN IK FORMAGc I [Lev.07!07199 <br />