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SAN JOAQUIN COUNT'r NVIRONMENTAL HEALTH DIV..,_ -)N MASTERFTLE RECORD LNFORNIATION FORIM (EH 00 69 New EH Program at Existing Facilitv ❑New EH Program and New Facility Facility ID V Program Record ID V) Facility Address '79 l U 0 i) /A- � �� , L�r'c 1 (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) L�orfile� D 5. ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -----Make Vehicle Type Color Registration # License # Sticker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color Registration # License # Sticker # ❑ Temporary Food Facility -----Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates 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 -----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -B Rule Household Hazardous Waste IXABOVEGROUND STORAGE TANK FACILITY (AST) (2390) ---Number of AST _ UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms HOUSING PROGRAM (2400) ❑ HotellMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housine/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site Cl 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ 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 ---Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ 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 n_ ol. xr;nI'r Pt, PROGRAM ELEMENT FEE Surcharge FEE Other FEE __j INSPECTOR #LIP PERMIT VALID to ❑ Food Handler ❑ Check # jkMOUNT PAID Date INVOICE # ❑ Cash REV1EwED BY� iy6& _3I tqj c,' ACCOUNTING OFFICE Date EH 0069 PINK FORM.doc 1— V1y111