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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI BION <br /> MASTERFILE RECORD INFORMATIOFORM EH 22! -9 <br /> N <br /> ❑ New EH Program at Existing Facility ew EH Program and New Facilit <br /> Facility ID D 1 'A (t{ Program Record ID <br /> Facility Address (/9 f r 614arfA 4 /AY <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Food Handlers Course required: YEs❑ No ❑ <br /> 11Restaurant: Seating Capacity Square Footage <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 <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from <br /> to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> CUP A ❑ 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 /> ❑ Permit-By-Rule Fixed Unit ❑ PetTnit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use!!STA and B Corns <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee llousine/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 HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Kennel <br /> ❑ Poultry Farm--Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> 11 Pumper Vehicle--Registration ri License# Capacity <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 /> ❑ Process/Recycle cle Facility El CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y ❑ Farm/Ranch Cleanu Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units P <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----❑ 2- 10-------❑ 11 -60------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIFS E110069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON !! Day Ph Night Ph <br /> PROGRAMELEMENT�Sy�� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID 7 j t0 ❑ Food Handler <br /> ❑ Check# AMOUNT PAID INVOICE# 6/04ya7 <br /> D <br /> 11 Cash REVIEWED BY ACCOUNTING OFFICE ate <br /> Rev.07/07/99 <br /> Ell 0069 PINK FORM.doc <br />