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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑New EH Program at Existing Facility cw EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address 22 S(o A) Uo`I l S o h <br /> (Please Check the appropriate description and specify si=e number of units andIt ertinent information.) <br /> FOOD PROGRAM(1600) <br /> ElRestaurant: Seating Capacity ` Square Footage good Handlers Course required: Yes ElNo 11ElCommissary ElDry storage only ❑ with Food Preparation gVending Machines—Number of Units — <br /> ❑ Retail Market----Square footage- El with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> C3Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker p <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 /> ❑ Pemut-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 fornis <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotcl/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Conon Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ U1C 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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farrar----Maximum number of birds - ❑ Kcanel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ 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 ❑ 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----112- 10-------❑ 11 -60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON -an P S Q 1 P.rl✓, I Day Ph q - 9SS Night Ph <br /> PROGRAMELEMENT FEE 2204eac x W - ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# n3 21 PERMIT VALID ? ' 308" to 7 .4. ❑ Food Handler r/ <br /> Check# 7 7 -D, AMOUNT D - - Date ! INVOICE# ��QT(o / <br /> 1 cash REVIEWED BY ACCOUNTINGOFI•lCG / Date <br />