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Algo <br /> SAN JOAQUIN COUNTY ENVIRONLAENTAL HEALTH DMSYON : <br /> iVLASTERFILE RECORD Nt FORlYL4TIOPf FORM(EH 00 69) <br /> Lx1.New EEE Ptogram at Extsting Facility ❑New EH irograrn and New Facility <br /> Facility ID t,)t.•L)L) ( Program Record ID c` 1 <br /> Facility Address <br /> (Please Check the appropriate description and specify sixc,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) _ <br /> ❑Restaurant. Searing Capacity_ Square Footage Food Handlers Course required- Yes❑ NO❑ <br /> ❑ Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending iylachines-Number of Units <br /> ❑ RetaiI Market----Square footage ❑ with Meat Market only ❑ Multiple Departraents ❑ Prepackaged G odso On yl <br /> ❑ Mobile Food Vehicle—Make Vehicle Type _ Color <br /> Registration# License rc Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Re.-istration# License# Sticker# <br /> ❑ Temparary 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 Dispeaser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) - <br /> H.AZARDOUS WASTE PROGRAM(2200) <br /> A,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 T,%NK(UST)PROGR_ PA(2300)Use UST and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HotcUitilotel-----Number of Uhits ❑ Jail or Exempt Institution Number of Units <br /> Employre Housing(2700)Use Employee floushrzILahor me A licarion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local R'W Cleanup Site ❑ NPLlSEP 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 Pools/Spas at FacilityCl Pool ❑ Spa ❑ Out of Service PooUspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 Poultry Farm Maximum number orbirds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> L.IQUED WASTE PROGRAm(4200) <br /> ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑ Pumper-Yard ❑ Package Treatment Plant ❑ Chemical Toilets Plumber of Units <br /> SOLID WASTE PROGRAM(4400) ' <br /> ❑ Landfill C1TraosferStation ❑Ag l Cannery Waste Site ❑ SLudgdAsh Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/RecycIe Facility ❑ CIA Landfill Site <br /> ❑ Dum stern>20 cu Y d---Number of Units - ❑ Farmlitanch Cleanup Site <br /> ❑ Refuse Vehicles-Number of Units p - <br /> MEDICAL WASTE PROGRAM(4500) <br /> [I Primary Care [3 Acute Care El Skilled Nursing '❑ Large Generator ❑Small Generator El i,imited Hauler.; <br /> ❑ Transfer Station C] Veterinary Clinic [3Common Storage Facility—112-10 ❑ it-60—0>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0064 Btue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON 0 Day Ph .`. f .��l r Night Ph <br /> PROCR.+.��tELEhIFsYtE l ©Surchaige{FEs ❑OtherF�lE <br /> 1 �l Prt1T VALID 1 t� to ', + - ❑Food Haridler�f <br /> 1.4SPECPOR# _ _ -- <br /> ❑ Checka AMOUNT PADace IWOECE .. , <br /> . ._Date ? • :, : ' <br /> ❑Cash REViEtivED BY . —ACCOUNTING O�tca T <br /> flea-0710T+99 <br />