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SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DIVIS N pp,YMENT MASTERFILE RI WINFORMATION FORM (EH 00 69) RECEIVED ❑ New EH Program at Existing Facility ❑Ncw EH Program and New Facility 7 zoo3 Facility ID D D(C(9 F( Program Record ID P4.p,51,2 O0F I OUT TY Facility Address V, 6W VjEkj iONI (Please Check the appropriate description and specify size,number of units and pertinent information.) ENVIRONMENTAL HEALTH DIVISION FOOD PROGRAM(1600) 7� restaurant: Seating Capacity c9a Square Footage lJ Food Handlers Course required: YES"o, No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit COPA O'State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-—Number of Units Employee Housing(2700)Use Employee Housing/Labor Canip Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------11 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Forn: EMERGENCY NOTIFICATION FOR THIS FACT ITY AND/OR PROGRAM CONTACT PERSON r�JJs� Day Ph }- Night Ph(iPD_.;2 PROGRAM ELESIF,NT p� F Surcharge FEE ❑ Other FEE INSPECTOR Its T ALID 1 to a I _ ❑ Food Handler [I'Check# AMOUNT PAID — Date_j INVOICE# Cl Cash REVIEWED BY ACCOUNTING OFFICE Date O s(3 r EH 0069 Pink Form Rev.02/25/03