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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> IMASTERFILE RECORD INFORl1LOTION FORM(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Program and New Facili <br /> Facility ID O bb 3-7 -11 Program Record ID P D 519 3a <br /> Facility Address 2-7 �J Ng y IDS <br /> (Please Check the appropriate description and specify size-number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes El No 11 <br /> ❑ Commissary ❑ Dry storage only C1 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 Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy Cl Milk Dispenser—Number of Contain in Multi-Head Unit <br /> COPA El State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator------------------Tans Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑ Perrnit-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 /> ❑ Jailor Exempt Institution—Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700)Use Employee Housin/Labor Camp Annfication 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 /> Cl Pool ❑ Spa C1 out of Service Pool/Spa [j Natural Bathing Area <br /> Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11Tattooing(4121) LJBody Piercing(4120) C3Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle—Registration# - License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> i <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site g <br /> ❑ Waste Tire Facility ❑ Compost Facility <br /> ❑ Process/Recycle Facility ❑ CIA Landfill Site <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 /> ❑ Common Storage Facility - 10—❑ it -60—13>60 generators <br /> El Transfer Station C3 Veterinary Clinic g ty <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON n Day Ph Night Ph <br /> PROGRAMELEMENT U1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 'j , 1 1 PERMIT VALID to ❑ Food Handler,_ <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVTEwED By ACCOUNTING OFFICE Date 'f Z <br /> Rev.07/07199 <br /> EH 0069 PINK FORM.doc <br />