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SAN JOAQUIN COUNTY NMENTAL HEALTH DIVIS ON <br /> MASTERFILE RECORD IINFORNATION FORM(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> FacilityAddress Ub C1 191'1* -1 <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: vFs❑ No 11 <br /> 1ante a Restaurant: Searing Capacity q g <br /> ❑ Commissary ❑ Dry storage only El with Food Preparation ❑Vepding Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C3 Mobile Type Color Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Registration <br /> # License# Sticker# <br /> Registration# C3 Ice Plant <br /> El Temporary <br /> Temporary Food Facility--Dates of operation from C1 produce Stand <br /> ❑ Special Event - Dates of operation from <br /> to <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year \J <br /> Hazardous Waste Generator--------------------- <br /> iered 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 /> ❑ HoteVMotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Em vee No sir �Labor CamO�I nnl7catian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ❑ UST-CAP Site 11 Local HW Cleanup Site 11NPUSEP 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 /> ClSpa C3 out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of pools/Spas at FacilityLJ pool <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity <br /> Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# <br /> ❑ Package Treatment Plant C1 Chemical Toilets—Number of Units <br /> ❑ Pumper Yard - <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> 1:1 Landfill Ll Transfer Station 11 Ar/Cannery Waste Site <br /> [3Process/Recycle Facility <br /> ❑ CIA Landfill Site <br /> C1 Waste Tire Facility El compost Facility C1Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <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 —❑ '-- 10--❑ 1 l -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PDMS EH0069 Blue Application Form <br /> T EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON J AL� WU�b Day Ph 36%- oIZ--7 Night Ph <br /> FEES— <br /> 13 Surcharge FEE El Other FEE <br /> PROGRAM ELEMENT Z?-2(] -1 to ❑Food Handler_�— <br /> INSPECTOR# _ PERMITVALID '= / <br /> ❑ Check# AMOUNT PAID �— Date - <br /> INVOICE# <br /> ❑ Cash REViEwED BY ACCOUNTING OFFICE <br /> i. _ Date <br /> Rev.07107199 <br />