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` SAM JOAQUIN COUNTY ENVIRONMENTAL:HEALTH DIVISION <br /> MASTERFELE RECORD INFORIMATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Prograrn and New Facility <br /> Facility ID Program Record ED 91P.t75\A <br /> Facility address VD-1 -n\t,a *zoc� <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: Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation _ ❑Vending Machines—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 ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA 13 State Facility Surcharge(2399) 13 221'( IL- 11-0-vice K"ck"v- <br /> HAZARDOUS WASTE PROGRAM(2200) � �f <br /> ❑ Hazardous Waste Generator-------------Toys Generated Per Year C GjTl7�S <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) - <br /> ❑ Pertnit-By-Rule Fixed Unit ❑ Permtit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑ Hotellivlotel-----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Emolovee Nou.sine/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessmeat ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ too-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pocls/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooVSpa ❑ 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 /> Cl Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units - 1 <br /> SOLID WASTE PROGRAM(4400) -- <br /> ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh 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 /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer-Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 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 �1�, �� Day Ph Night Ph <br /> PROGRAMELENIENT FEE ❑Surcharge FEE ❑ Other FEE — <br /> INSPECTOR# _ � PERMrr VALID to - ❑ Food Handler. <br /> Check# Ab10UNT PAID Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNMa OFFlCE Date <br />