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SAN JOAQUIN COUN i ENVIRONMENTAL HEALTH DI-v,,ION <br />MASTERFILE RECORD LNFORNL4,TION FORM (EH 00 69) <br />New EH Program at Existing Facility []New EH Program and New Facility <br />a Facility ID („yam i—A Program Record ID r, ,i 444-(->i-, <br />Facility Addresses <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail ivlarket ----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 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 Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZAF,DOUS WASTE PROGRAM (2200) <br />,d 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 TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ HoteUMotel------- Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee HousinzlLabor Camp Ann/icarion 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 />Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds ❑ Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ 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 />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2 - 10 -- ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PII'S EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Dav Ph Nieht Ph <br />PROGRAM ELEMENT FEE ❑ Surcharlge FEE C3 Other FEE <br />INSPECTOR # PERMrr VALID ( 1 0 — to I`�13 1 Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REViE%VED BY ACCOUNTING OFFICE Date <br />EH 0069 PINK FORM.doc , O Q n d 5'� O /O -. 60 C 5C) V Rev. 07M nvv <br />