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SAN JOAQUIN COUNTY ENVIRONMENTAI,HEALTH DI N <br /> M�STERFILE RECORD L IFORt�LATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facili ID dd Program Record ED <br /> Facility Address 70 A 1pd . . 11)r►J EL 12� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Food Handlers Course required: Yes ❑ No ❑ <br /> 11Restaurant: Searing CapacitySquare Footage <br /> [] Commissary ❑ Drystorage only ❑ with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color T <br /> Type C3 Mobile Food Vehicle---Make VehicleSticker# <br /> Registration# License <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Sticker# <br /> Color <br /> RRegistrationation# License# <br /> to Cl Ice Plant <br /> C3 Temporary Food Facility--Dates of operation from C3 Produce Stand <br /> ❑ Special Event - Dates of operation from to <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 /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> Hazardous Waste Generator-------------------- <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 /> ❑ Jail or Exempt Institution—Number of Units <br /> ❑ HoteUivlotel-------Number of Units <br /> Employee Housing(2700) Use Employee Ho sit -_ILabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C3UST-CAPSite ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br /> C1 Abandoned HW Site C1 non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) 0 Out of Service PooUSpa ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kenner <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) Ca aci Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# Capacity. <br /> [I Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units�— <br /> i <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑Ar/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility C3Farm/R2nch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small❑G I Generator 13>t60 generratorsr <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- IO-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> �7 tj O ❑SurchargeFEE ❑ Other FEE �-- <br /> PROGRAM ELEh1ENT Z > FEE C—�� ^ ❑Food Handler <br /> INSPECroR# _ PERMITVALID 1/1 to I^�l�l IOo2 <br /> ❑ Check# AMOUNT PAID -- Date--T�— VOICE#��' <br /> ./ ACCOUNTING OFFICE Dale ��- <br /> ❑ IE <br /> Cash REVIEWED BY Rev.07/07/99 <br /> FH 0069 K FORM.doc <br />