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SAN JOAQUIN COUNT1 sNVIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM EH 00 69 ❑New EH Program at Existing Facility ❑New EH Pro ram and New Facility Facility ID F�oC 14 I2 p Pro rain Record Ill Q 7-3 j(�7 Facility Address lyo i V (Please Check the appropriate description and specify size,number of units and pertinent informa(ion.) FOOD PROGRAM(1600) �Restaw•ant: Seating Capacity� Square Footage Food Handlers Course required: YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation [:]Vending Machines--Number of Units ❑ Retail Market----Square footage ❑ with Mcat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Stickcr It ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation ` from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(ones HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jailor Exempt Institution-----Numbcr of Units Employee Housing(2700) Use Emplonee ffousinr/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Arca VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-----Maxinwm number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vchicic--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludgc/�1�Ii,S�to �;. El Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility ❑ CIq•�atit 011 ite El Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Falki 7ienclt Cicio;;Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator L7 Cimited Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10-------❑ I 1 -60------11>60 gsa"t PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E1f0069 Blue Application Form eN�4O��N�``�4p� E G Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONDay Ph 2�'I )�8'�3'1' - Night Ph PROGRAM ELEMENT Z FEE '~" ` ❑ Surcharge FEE ❑ Other FEE 9-chcck PECTOR# 33e I PERMITVALID I I C, ��— to , �O G ❑ Food Handler>♦ I e J AMOUNT PAID ,��O Date_ �' 1 (�� 1Z-fNVOICL•# Cash REVICWCD BY pTV ACCOUNTING OI.-FICG VD Date CII(i 69 PINK F01W.doc o Rcv.07/07/99