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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DIVIS1%jN <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> LNew EH Program at ExistingFacili ❑New EH Program and New Facili <br /> ID Program Record ED R/a 515 7 <br /> Facility Address N� .( ^�r2t �►U�� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600)I(Pi9 <br /> 11 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES El No C1 <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 /> El Temporary Food Facility-----Dates of operation from to 11 Ice Plant <br /> ❑ Special Event - Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy 11 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 /> ❑ Permit-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 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> ❑ Hotel/Motel-------Number of Units Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700)Use Employee Housing/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 /> Number of Pools/Spas at Facility El Pool El Spa [1 out of Service Pool/Spa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Kennel <br /> ❑ Poultry Farm----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ A /Canne Waste Site ❑ Sludge/Ash Site <br /> El Landfill 11 Transfer Station g �7 <br /> ❑ Process/Rec cle Facility ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility Y h <br /> umber of Units El Cleanup Site <br /> ❑ Refuse Vehicles--Number of Units 11Dumpsters>20 cu yd----N <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care 11 Acute Care 11 Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ----❑ Z- 10-------11 1 I -60------❑ >60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic El Common Storage Facility <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDD/OR PROGRAM <br /> CONTACT PERSON'Al nom Day Ph AJD(D — `I(_ Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# L 13. ? PERMIT VALID �Dom_ to I Z ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Z 3 60 <br /> Rev.07/07/99 <br /> EH 00o9 PINK FORM.doc <br />