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• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD Iii 1FORNL4,TI0N FORNI (EH 00 69) <br />❑ New EH Program at Existing Facility eW EH Prnonm and tYnw Fnriiiw <br />Facility ID Program Record ID i 2O6-9 ( S0 to <br />Facility Address _ lg03 �. 'Y�p(7Y) I'A g52 -OS <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES ❑ Yo ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending PyIachines -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 ❑ iYlilk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) ��-�� Il�ay�Ce IQpn� �G,� <br />HAZARDOUS WASTE PROGRAM (2200) ""J"� <br />❑ Hazardous Waste Generator ---------------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 TAINK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) - <br />❑ Hotel/Motel-------Number of Units ❑ Jailor Exempt Institution Number of Unit <br />Employee Housing (2700) Use Employee Housine/Lahor 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 Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles —Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Kennel . <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />ElChemical Toilets Number of Units <br />❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care Cl Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —112 - 10 ❑ 11 - 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 />PROGRAM ELEMENT <br />-7 FEE _ <br />INSPECTOR PERMIT VALID <br />❑ Check # A, ou lT PAID _ <br />❑ Cash REVIEWED BY <br />r <br />❑ Surcharge FEE, <br />to <br />❑ Other FEE <br />❑ Food Handler <br />Date INVOICE If <br />ACCOUNTING OME -1,L Date 5 <br />