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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> [� New EH Program at Existing Faciliry ❑New EH Program and New Facility <br /> 'Facility ID _ (%& Program Record ID <br /> Facility Address 2 7 3' ',� Cc;L,)�j jj� L Lvo <br /> (Please Check the appropriate description and specify size number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yrs❑ No ❑ <br /> ❑ Commissary ❑ Drystorageonly ❑ with Food Preparation ❑Vending Machines—NumberofUnits <br /> ❑ Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration X License# Sticker X <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration N I License tF Sticker ft <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 USTA and 8 forms <br /> HOUSING PROGRAM(2400) <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 PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number ofbirds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration a; License Capacity Vehicle q <br /> ❑ Pumper Yard - ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> i <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landoll ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ SludgelAsh Site <br /> ❑ Waste Tire Facility C3 compost Facility cycle <br /> ❑ Process/Re FacilityEJ CIA Landfill Site <br /> ElRefuse Vehicles—Number of Units El 'Dumpsters>_0 cu yd—Number of Units 1:1 Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Statioa ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10—❑ It-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form - <br /> EMERGENCY NOTIFICATION FORTHis FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT rJ FEE . OU ❑ Surcharge FEE ❑ Other FEE —� <br /> INspEc,roR# 3 1 PERMIT VALID to ❑ Food Handler <br /> ❑ C-heckR AMOUNT PAID Date INVOICE# ' <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date a/ 0 Z <br /> Rev.07!07/99 <br /> r:w anAg PINK FORM.doc <br />