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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV MON <br /> MASTERFILE RECORD INFORMATION FORNI(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Pro and New Facility <br /> Facili ID 00150 S-1-16 Program Record ID 3� <br /> Facility Address I L19 I �^ <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs 13 No ❑ <br /> ❑ Commissary 13 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 /> C1 Mobile Type Color Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type <br /> Registration# License# Sticker# <br /> ' to [I ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ produce Stand <br /> El Special Event - Dates of operation from to <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) 5 / <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year d <br /> X Hazardous Waste Generator-------------- ❑ Cond Ilona!! Exempt CE <br /> Tiered Permitting Facility 0 peg°By Rully le Fixed Uniuthorized t ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and 8 forms <br /> HOUSINGM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> ❑ HoteVMotel-------Number of Units <br /> Employee Housing(2700) UseEmnlovee No aAor Camn Annlicatian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Sit <br /> e ❑ UIC Site <br /> El Abandoned HW Site 11 non-NPL/SEP Cleanup Site C1 RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service PooVSpa ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ 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) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# - License# P tY <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> i <br /> SOLID WASTE PROGRAM(4400) Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station 13 Ag/Cannery Waste ❑ Slu Landfill Site <br /> ❑ Waste Tire Facility [3 Compost Facility 11Process/Recycle Facility <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 13 Large Generator ❑ Small❑Gi Generator Limited elratorsr <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--❑ 2- 10— <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 B/ue Annlieadan Form <br /> EMERGENCY NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> PROGRAM ELEhIENT Z 2 2 O FEE 2©_ 0•V V ❑ Surcharge FEE E3 other FEE <br /> �— PERMrr VALID to ❑Food Handler—� <br /> INSPECTOR# INVOICE# OD Y7LI-7 <br /> AMOUNT PAID Date <br /> El Check# � I Date 7 y D a- <br /> ❑ Cash REVIEWED BY ACCOIIM Gi OFFICE <br /> Rev.07/07199 <br /> FH 0069 PINK FORMAcc <br />