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` SAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION IMASTERFILE RECORD E FOPUMATION FORM(EH OO 69) New EH PraTM at Existing Facility ❑New EH Program and New Fa'-Cility Facility ID �� Program Record ID Facility Address ac0 -6�. (+1Gc +rte' 1N � (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacitym__ - - ---- -Square Footage Food Handlers Course required: Yrs❑ 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 Uait—Make Vehicle Type Color Registration# License It Sticker# ❑ Tempo,rary Food Facility----Dates ofoperation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand i DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) p 2211 il ,n,Y1CeG�- ! H.42ARD�J5 WASTE PROGRAM(2200) azardous'Waste Generator--------------Tons Generated Per Year Tiered Permitting Facility ❑ ConditionaIly Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST i UNDERGROUND STORAGE TANK(UST)PROGFUM(2300)Use UST A and S Lorms HOUSING PROGRAM(2400) ❑ HoteUivlotel-------Number of Units ❑ Jail or Exempt institution Number of Units Employee Housing(2700)Use Emplp ee Housinb/Lahor Camp Application Form ! 1 SITE MITIGATION(2900) UNDERGROUND wir=c-ETON CONTROL 3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local 11W CIeanup Site ❑ NPL/SEP Cleanup Site ❑ UIC site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site a RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool C1 spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) t ❑ 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 9 License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets, Number of Units SOLID WASTE PROGRAM(4400) -- ❑ Landfill ❑Transfer Station ❑Ag 1 Cannery Waste Site ❑ Sludge/Ash Site 11 Waste Tire Facility 11Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—dumber of Units ❑ Dumpsters>20 cu yd----Number of[hits ❑ Farm/R2nch 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 EHOO69 Blue A licadon Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANGOR PROGRAM E CONTACT PERSON Day Ph - Night Ph I PROGRA,MELEENI(EcN�T FEE ❑Surcharge FEE ❑ Other FEE INSPECTOR# au-I PERMIT VALID ...to ❑Food Handler_------- ❑ ctreck# A��tolriT PAID Date INVOICE# al I ❑ Cash REvMVED BY ACCOUNTING OFFICE Date -.___ nam169 __l.