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G SAN JOAQUIN COUNTY Ei l VIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID U 0 s3 Program Record ID 05-/( sal <br /> 'Facility Address �2 C70 e/7�-DOOCJ f <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) j/�1 � 4 <br /> FOOD PROGRAM(1600) �lJ� <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YESNo 11❑ Commissary ❑ Dry storage only Elwit ood Preparation ❑Vending Machines—Number of Units <br /> P, <br /> 9Retail 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 /> ❑ 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 /> ❑ 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/brims <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution---Number of Units <br /> Employee Housing(2700) Use Employee HousinglLabor Camp Application For : <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 Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-----Maximum number of birds ❑ Kennel <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# 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 Generatorbler <br /> ElTransfer Station ElVeterinary Clinic ElCommon Storage Facility ----❑ 2- 10-------111 1 -60------ Mgn <br /> JJ Jors <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form SEP 2 9 2000 <br /> ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> --7 CON RSO�- � — ay Ph _ Night Ph SoANa JO�AQUIN�COUNTY <br /> n t .. <br /> P1 NI ELEMENT EE ! Surcharge FEE ❑ Other FEE <br /> INSPECT 9 to -3y G El Food Handler <br /> ❑ Check# AMOUNT PAI �D Date q1�9 I INVOICE# ��-76,x3 3 <br /> Cash REVIEWED BY 2 Oo ACCOUNTING OFFICE Date <br /> EH V',69 PINK FORM.doc Rcv.07/07/99 <br />