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SAN JOAQUIN COUNTY MI VIRONMENTAL IIEALTH DIVISr6N 1 <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> :Facili[ ID "Pro raniRccord ID <br /> Facility Address LE Y�) Lo. Ifs S+ . _::4ac� 3-1(-9- <br /> I <br /> (Please <br /> ­1 -R- <br /> (Please Check the appropriate description and specify sizenumber of units and uerlinent information.) <br /> FOOD PROGRAM(1600) <br /> _ licstaurant: Seating Capacity CIC) Square Footage Food Handlers Course required: Y No E <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage ❑ with Mcal Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration N License II Sticker It <br /> ❑ Mobile Food Prep Uuit--Make Vehicle Type Color <br /> (Registration 9 License 0 Slicker N <br /> ❑ Temporary Food Facility-----Dates of operation from - to ❑ Ice Plant <br /> ❑ Spccial Event - Dates of operation ' from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade D Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ Stale Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ IIazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pcrmil-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 D forms <br /> HOUSING PROGRAM(2400) <br /> ❑ hotel/Motel-------Numbcr of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee(lousing(2700) Use Entidovee/lopsinrlLabnr Cmnt,Application Farrel <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Walcr Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas.at Facility ❑ Pool ❑ Spa ❑ Out of Scrvicc PooUSpa ❑ Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Fano------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vchicic--Registration It License H Capacity - Vehicle N <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--Numbcr of Units 1:1 Dumpsters>20 cu yd----Number of Units ❑ Farnl/Raneh Cleanup.Sile <br /> MEDICAL WASTE PROGRAM(4500) r Q 3,SV <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ElLarge Generator ❑ Small Generator 'tI Limitfd; J \GESg\ON <br /> ❑ Trans(cr Station ❑ Veterinary Clinic ❑ Common Storage Facility ----112- 10-------❑ 1 I -60------0,>', � �rs <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069Dlae Application Form �!�7��\Q�\\t <'�' S+"'. <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (D `J <br /> CONTACT PERSON t7,, ) � ''(i -2 �_�Z ` <br /> �� � DayP -� � �,�' �t�'�, �-}NlghtPh <br /> I.. . <br /> PROGRAMELEMENT FEE Surcharge FEE Other FEE <br /> INSPECTORII PERMIT VALIDto ❑ Food Handler <br /> ❑ Chcck9 AMOUNTPAID Date INVOICEII J <br /> :1 Cash RCVILwGD 13Y �ACCOUNTING OFFICn' <br /> Dale -- <br /> EH oP69 PINK FORM.doc s Rev.07/07199 <br />