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SAN JOAQUIN COUNTY L gVIRONMENTAL HEALTH DIVIS1 jNN <br /> L MASTERFILE RECORD <br /> gg �� <br /> INFORMATION FORM(EH 00 69) <br /> ❑ New EH Program at ExistingFacilityg4D�'Y'W ❑Ncw EH Program and New Facility <br /> Facility ID Program Record IDIZ-O Sig�ly' <br /> Facility Address �' ? h� Y�[filE?Jt�i % C� 85376, <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOD PROGRAM(1600) <br /> Rcstaurant Seating Capacity('J Footage L.t Food Handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Mcat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License it 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 /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pertuit-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 R forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotel/Motcl-------Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee(lousing(2700) Use Emolovice flousine/Labor Camp Application 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 IIW 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farni-----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 Vchicle--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 ❑ Sludgc/Ash= <br /> 11 Waste Tire Facility ❑ Compost Facility -❑ Process/Recycle Facility 1:1 CIA La —Olt <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd ----Number of Units ❑ Farm/Ra t l eand to <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑t&lt 'yau <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----02- 10-------❑ 11 -60------11 >60 mtl ``' <br /> �2 <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form y Q0�2 <br /> // EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON &IV�Jr✓1�6, � AO Day P `� � JC' & N i g h t Pt(,w"/��1� 1� <br /> PROGRAM ELEMENT I FEE 2 Z ❑ Surcharge FEE ❑ Other FEE <br /> I,�NS�PECTOR# -�-� b ( PERMIT VALID - :;�;,� to _ ❑ Food Handler <br /> 11YCheck# AMOUNT PAID DateINVOICE# 97��z <br /> l Cash REVIEWED BY L AccouNnNc OEPtce Date ( 6Z <br />