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SAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV/ ON <br /> MASTERFrLE RECORD INFORMATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility LD Program Record ED v <br /> FacilityAddress (-1�0 1 Lao <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare 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 VehicleTvpe Color <br /> Registration# License# Sticker <br /> ❑ Temporary Food Facility--Dates of operarion from to El Ice Plant <br /> ❑ Special Event - Dates of operation from to El 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 /> 1-,&ZARDOUS WASTE PROGRAM(2200) C T SS /t, <br /> Hazardous Waste Generator--------------------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 /> ❑ HoteUMotel-------Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee N t sig ^/Lahor Camp Application 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 PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> C3 Pumper Vehicle—Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> C1 Landfill C1 Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> I Site <br /> ❑ Process/Rec cle Facility ❑ CIA Landfil <br /> El waste Tire Facility Cl Compost Facility Y <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—❑ 11 -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 PERSONTyr � rmCf CVN Day Ph CZOZia —3Z3j Night Ph <br /> PROGRAM ELEMENT 2 v� FEE ❑Surcharge FEE ❑ Other FEE <br /> PERMIT VALID @ y L2 to 17-� 6(0?� ❑ Food Handler <br /> INSPECTOR# �38� -�t- - <br /> ❑ Check# AMOUNTPAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNrNGOMCE Date <br /> Rev.07101"99 <br />