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� 1 <br /> SAN JOAQUIN COUNTY E11W1R0NWMNTAL HEALTH DMS _ <br /> MA.STERI+`>ELE RECORD INFO ATION FGRM EH 00 69 <br /> ❑New 6H Program at ExistinS Facility ❑New EH Program and New Fxcili <br /> FBtlll )® - R0Cbrd W rN' <br /> Facility Address 37 West Sonora Street <br /> (Please Check the appropriate description and specify QIP. number of units and pertinent information.) <br /> FOOO PROGRAM(1600) <br /> ❑Restaurant Seating Capacity _ Square Footage Food Handlers Course required: iYps❑ No 0 <br /> ❑ Commissary ❑ Dry storage only Q with Food Preparation ❑Venuing Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Dcpartmentc ❑ Prepackaged Goods Qnly <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker fi <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License 0 Sticker# <br /> Temp9mry Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Sp.efat Rvent - Dates of operation from to © Produce Stand <br /> DAIRY PRDGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ NI11k Mstwnser---Number of Containers in Multi-Head Unit <br /> C_ U ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste GeneratorGonetated Per Year <br /> Ticred Permitting Facility ❑ Conditionally Authori2ed(CA) ❑ Conditionally Exempt(CE) <br /> ❑ permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ASOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UTA and B formes <br /> Hpt1SING PRQG-RAMI(2400) <br /> 0 RotelIMotd-------Number of Units ❑ 3311 or Exempt rnstitutl*u---Number of Unitg <br /> E.nrpbYce ilousiu=(2700)Use Et" es Form <br /> 31TE MITiCATION(29W) NJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleantlp Site ❑ NPLISEP Cleanup Site ❑ UTC Site <br /> ❑Abandoned HW Site ❑ non-NPLSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RE!REATIONAL HEAL" PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of service Pool/Spa ❑ Natural nothing Area <br /> VE OR CO OL PROGRAM(4000) <br /> ❑ Poultry Farm--- Maximum number of birds ❑ Kennel <br /> TATT001 BODY PIERCING PERMANENT CO3ML'TIC rI ognAM(4100) <br /> ❑Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> 1�,IARID WMTE PRO) RAMI(4200) <br /> Q Pumper Vehicle—Registration# License rl Capacity Vehicle# <br /> IJ Pumper Yard 13Cbemic <br /> Package Treatment Plant ❑ al Toilets-----Number of Units <br /> SOLID WASTE PROGt2AM(4$00) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery waste Site ❑ Sludge/Ash Site <br /> Q Waste Tire Vacuity d Compost FRcltity ❑ Process/Reeyelo Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Unite ❑ Dumpsters>20 cu yd----Numbtr of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WA2T9 PROGR (4500) <br /> ❑ Primary Cage ❑ Acute Care ❑ Skilled Nursing C7 Large Generator 13 Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---❑ 2- 10---—❑ 11 -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS ER0049 Slue Apnlitation Fort <br /> EMt_Rt"aEHr-Y NOTIFICATION FOR TN15 FACILM AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ SurchargeF'EE ❑ Other FEE <br /> INSPECTOA# PPR mrr VALID to 13 Food Handler <br /> ❑Check# AMOUNT PAID Date INVOICE <br /> ❑Cash REVIEWED Ry ACCOUNMNG OFFICE Date <br /> EH 000 PIN 1=ORM,doc Rev.07/07M <br />