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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI I3iON <br /> MASTERFILE RECORD INFORMATION FORM(E 69 <br /> New EH Program at Existing Facility ❑Ne H Pro and New Facili <br /> FacilitpID DG Program Record A G5�/3.36— <br /> FacilityAddress 3 <br /> (Please Check the appropriate description and specify size number of nits and pertinent and <br /> FOOD PROGRAM(1600) _F_ <br /> ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course r uired: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines— mber of Units <br /> ❑ Retail btarket----Square footage 101 with Meat t rke[only ❑ Multiple Dep pts ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle a 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 /> FLAZARPUS WASTE PROGRAM(2200) �_� <br /> azardous Waste Generator------------------Tons Generated Per Year (J <br /> 'j 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 /> ❑ HoteVpylatel-------Number of Units ❑ Jailor Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Hops' /Labor 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 Fools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm—Maximum number ofbirds C1 Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> C3 Tattooing(412 1) 11 Body Piercing(4120) C] permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# 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 Eludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility 11Process/Recycle Facility ElCCIA Landrdl Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmfRanch 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—112- 10—❑ I t-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Aeglicadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON nnTM '1Day Ph ��1 '��� ('t 6 Night Ph <br /> PROGRAilvt ELEMENT �4`e2 a FEE ❑ surcbargeFEE- ❑ Other FEE <br /> INSPECTOR# 73 PERMIT VALID (� to - ❑ Food Handler_ <br /> ElCheck# AMOUNT PAID at Ll— Date INVOICE# I�QS— <br /> ❑ Cash REV[EWEDay ACCOUNMGOMF E y- Date <br /> Rev.07107/99 <br /> cu MRa RM[C Fr1RU Ary <br />