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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD Pi iFORIVIATION FORM(EH 00 69) <br /> New EH Pro a[ExistingFacility <br /> ❑New EH Pro and New Facility <br /> Facili ID FPavr7a� Program Record ID FQ 0 518 745 <br /> Facility Address5a �e'�'tL pUvIc <br /> (Please Check the appropriate description and specify sim number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yes❑ No ❑ <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> C] Commissary ❑ Dry storage only <br /> ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage El with Meat Market only [I Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type _ Color <br /> C1 Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> ElMobile Food Prep Unit—Make Vehicle TypeLicense# Sticker# <br /> Registration# to ❑ Ice Plant <br /> C3 Temporary Food Facility--Dates of operation from [o C3 Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy ❑ Grade B Dairy <br /> CUP A ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> Tons Generated Per Year <br /> ❑ Hazardous Waste Generator Conditionally <br /> onditio l ut ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Facility ❑ ContGtiEly-R Authorized(CA) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-IIy-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 /> HOUSINGPROG—RAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> ❑ HoteUMotel-------Number of Units <br /> Employee Housing(2700)Use Emaloyre��Lanar Cama rlan GROUon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UTC Site <br /> ,,r Cleanup Site <br /> ❑ Environmental Assessment El UST-CAP <br /> un-CAPS it Cleanup Ste Local HW Cleanup <br /> RWQCB Cleanup❑Site LN P�S❑Water Quality Remediation oo S'de <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) Cl put of Service Pool/Spa <br /> Natural Bathing Area <br /> Number of pools/Spas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC erc ng(41120)(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) y <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# P ry <br /> ❑ package Treatment Plant C] Chemical Toilets—Number of Units <br /> C1 Pumper Yard - <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑Transfer Station [3 Ag/Cannery Waste Site CIA Landfdl Site <br /> El Landfill [IProcess/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ it —060 ❑>60 generators <br /> 13 Transfer Station C3 Veterinary Clinic Common Storage Facility —❑ '-- IO-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Aoplicatiort Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph� Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> FEE 220 ❑ Surcharge FEE <br /> EFROCRAM ELEMENT U � ❑ Food Handier�, <br /> .�ay,A PERMITVALID °ECTOR# -TT-> jdVOICE# <br /> AMOUNT PAI ate heck# � DateD ash REVIEWED BY <br /> ACC-U r.OFFICE Rev.07/07199 <br />