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p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> ❑New EH Program at Existing Facility ❑Ncw EH Program and New Facili <br /> -Facility ID - Program Record ID i`k ' <br /> Facility Address/�l.2 E ����rr Tf= /✓✓ �S'NTP�I' iSS3/z <br /> (Please Check the appropriate description and specify sic number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Pd Restaurant: Seating Capacity/GZ Square Footage 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 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 /> ❑ Gradc A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pernilt-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 /> ❑ Iiotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Fpmlovee Housinr/Labor Caam Application Farm <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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca <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) ��PAYr�i\/IE-,A , <br /> ❑ Pumper Vchicle--Registration# License# Ca'phi;in`�F"/F,. Vehicle# _ <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemict'Fpilets,--a-A"cr of Units <br /> SOLID WASTE PROGRAM(4400) " L U ' <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Was W& W�uUIN I:r.. ❑ Sludge/Ash Site <br /> PJ� LIC hET I"," <br /> �rt ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility -❑ Process/Recycle�yp 4WLI HE• <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 r;H0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSO P Y Day Pl(�U/`-��/>�ALL Night Ph (y1�� ZZ F'— <br /> PROGRAM ELEMENT /(D 2(, FEE 2 7 U ❑ Surchargfg FEE ❑ Other FEE <br /> INSPECTOR# U I " PERMIT VALID /0 Gto 0131 lb;P— ❑ Food Handler <br /> ❑ Check# AMO T PAID Date 'D130/D l INVOICE# d 0'�e <br /> , Cash REVIFWEDnACCOUNTING OFFICE Date / L/ <br />