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SAN JOAQUIN COUNTY ENVIROMMENTAL HEALTH DI ON <br /> MASTERFLLE RECORD LNF0R1?vLkTION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility LD t A- 0 17 1 t{d( ( Program Record ID a O Sa I <br /> Facility Address <br /> (Please Check the appropriate description and specify side number of units and pertinent information.) <br /> FOOD PROGRAM(1600) lr - <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES❑ No Cl <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 ❑ State Facility Surcharge(2399) - -- <br /> / H-4ZARI}0US WASTE PROGRAM(2200) <br /> ErHazardous Waste Generator------ —Togs 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 /> ❑ HoteV?vfotel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use E olo vee Housi WLahar Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP 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 Fools/Spas at Facility ❑ Pool ❑ Spa ❑ Out or service Poouspa ❑ 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 /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill . C1 Transfer Station 11Ag/Cannery Waste Site [1 SludgelAshSite <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ PmcesslRecycle 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 Day Ph Night Ph <br /> PROGRAM ELEMENT 27761 FEE ❑Surcharge.FeE ❑ Other FEE <br /> INSPECTOR# 7 PERMIT VALID ll2( �G 3 to C3 ❑ Food Handler L'� <br /> ❑ Check# AMOUNT PAID /i>t.[.fr C— Date INVOICE# 1 1 L�- <br /> ❑ Cash REVIEWED BY ACCOUNNNG OFFICE Date <br /> EH 0069 PINK FORMARev.07/07/99 <br />