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S?u�i JOAQUIN COUN1- ENVIRONMENTAL HEALTH DI*q6ION <br /> MASTERFELE RECORD INFORMATION FORM(EH 00 69) <br /> ❑New EH Program at Existing Facility vvew EH Program and New Facility <br /> Facili ID FA ew lc -7e?/ Program Record ED 0 -/7 q,2& <br /> FacilityAddress tJ, <br /> (Please Check the appropriate description and specify size number of units and pertinent in ormation.) <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 /> CUP A X5 tate Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) G <br /> Hazardous Waste Generator ---�9?'02-Q—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 TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteUlytotel------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housine7Lahor Camp'Annlication 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 Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooL/Spa ❑ 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(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Regisrrarion# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) - <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ 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/Rancb 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—❑ 11 -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form 4.le <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY/A�N/D/OR PR RAM <br /> CONTACT PERSON Day Ph TIO 5 rJ 77 Night Ph <br /> PROGRAM ELEMENT rJ , a/) FEE 42OC• 13 Surcharge FEE 11 Other FEE <br /> INSPECTOR# [�Do PERMIT VALID ,l''a010 I to 15" ( () I ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date r—� INVOICE# 00.,V 40 7 n � - <br /> ❑Cash REVIEIVEDBY ACCOUMING OFFICE cLilb Date ` I7r01 <br /> EH 0069 PINK FORMA. p � Rev.07/07/99 <br /> �F- �j4�4.�1�IYl P'r•'✓v<<{p//� �'����� !/1 "/'ICJ <br />