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1 <br /> SAN JOAQUIN COUNTY-ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD L`IFORMATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID 5' Proaram Record ID S/ <br /> FacilityAddress UX0 InI6#-'tj� <br /> (Please Check the appropriate description and specify site,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No C1 <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 /> . <br /> C1 Mobile Type Color Mobile Food Vehicle---Make Sticker# <br /> Registration# License# <br /> 11 Mobile Type Color <br /> Mobile Food Prep Unit--Make Sticker# <br /> Regigistration# License# <br /> to 11 Ice Plant <br /> 11Temporary Food Facility--Dates of operation [Tom 11 Produce Stand <br /> ❑ Special Event - Dates of operation from t0 <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-4ZA"OUS WASTE PROGRAM(2200) <br /> Hazardous Waste Generator---------------------Tons Generated Per Year L S � <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Perm t-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 /> ❑ Jail or Exempt Institution—Number of Units <br /> C1 FloteUhiotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Cama Apolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site LlNPWSEP 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 /> ❑ <br /> ❑ Pool Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility <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) Vehicle# <br /> ❑ Pumper Vehicle—Registration# <br /> License# - Capacity <br /> ElPumper Yard C1Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station <br /> ❑ Process/Retycle Facility ❑ CW Lapdfdl Site <br /> 11 Waste Tire Facility ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing El Large Generator ❑ Small Generator El Limited Hauler <br /> cility--❑ 2- l0--[I I I -60--❑ '60 generators <br /> Cl Transfer Station ❑ Veterinary Clinic C3 Common Storage Fa <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Aaplication Form <br /> Q `r EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON "t`"v`�a ( OSSlt,� DayPh�J00 SNightPh <br /> PROGRAM ELEMENT 7-720) FEE 11 11Surcharge FEE El Other FEE <br /> PERMIT VALID 6 10 ❑ Food Handler�— <br /> IYSPECTOR# `�31 �I1 <br /> 11 Check# PLMOUNT PAID Date INVOICE# <br /> ) � <br /> ACCOUNTING OFFICE Date <br /> NJ <br /> 0 Cash REViEtiyED BY -rrn7'99 <br />