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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MIASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> tiew�EHPro�rarn at Existin Facility ❑New Elf Pro ram and New Facility <br /> FacilityID } C ( Pro ram Record 1D S --(yy Jf <br /> Facility Address , <br /> (Please Check the appropriate description and specify size,number of its a d pertinent infor tion.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required; YES❑ No ❑ <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 /> ❑ <br /> Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Stickcr# <br /> ❑ 'Temporary Food Facility-----Dates of operation from to ❑ lee 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 ❑ Recycle/Exempt System <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 /> (UST) { ) and B(arms <br /> UNDERGROUND STORAGE TANK US PROGRAM 2300 Use US7'A <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housitr !Labor Cam Application Forth <br /> MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> IRviron mental Assessment ❑ UST-CAP Site ❑ Local W leanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> bandoned HW Site ❑ non-NPLISEP Cleanup Site RWQCB Cleanup Site 11 Water Quality Remediatlon Site <br /> CREATIONAL HEALTH PROGRAM(3600) ; , 300 <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 of birds ❑ 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# License# Capacity Vehicle# <br /> ❑ Pumper Yard 1:1Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag I 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 Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -6D------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 htlueApplicadoit Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FRE ❑ Other FEE <br /> I}}}N(((SPECTOR# � PERM11-VALID to El Food Handler Q <br /> Check# j�`�� 4 1 I FL1�AMOIINT PAIDO <br /> Date �L1(-1NV0lCE#%FLJ :�E� '< E <br /> Cash REvfEwrr)av ACCOUNT[NG OFFICE , -- Date j <br /> F11 0069 Pink Form Rev.02/25/03 <br />