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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑ New EH Program at Existin, Facility <br /> RNCW EH Program and New Facility <br /> Facility ID 0/95— Pro ram Record ID <br /> Facility Address 8-'-7 L(-) L,-,-) s-r-oC e -,-o <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> l�l Restaurant: Seating Capacity 86 Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation P ❑Vending Machines--Number of Units <br /> ❑ Retail 1VIaSquare footage <br /> N9obile Foodod Vehicle ❑ with Meat Market only ElMultiple Departments ❑ Prepackaged Goods Only <br /> ❑ <br /> Registration if Vehicle Type Color <br /> ❑ <br /> Mobile Food Prep Unit--Make License# Sticker it <br /> Vehicle Type <br /> Registration# Color <br /> ❑ Slicker#Temporary Food Facility-----Dates of operation from License# <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> f0 ❑ Produce Stand <br /> ❑ Grade A Dairy ❑ Grade B Dairy 13 Milk Dispenser---Number of Containers in Multi-}-[cad Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIALARD0US 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 ❑ Pennit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGIZOUND STORAGE TANK FACILITY(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ flotcl/rvlotcl-------Numbcr of Units ❑ Jail or Exempt Institution-------Numbcr of Units <br /> Employee!lousing(2700) Use Emplovee llmis ne/I ahor Camn ARE Cahan Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ <br /> Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC site <br /> ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Numbcr of Pools/Spas at Facility ❑ Pool ❑ Spa P ❑ Out of service Pool/Spa. El Natural Bathing Arca <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Kennel <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# License# <br /> Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> ❑ Chemical Toilets-------Numbcr of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ Waste Tire Facility 13 Compost ❑ <br /> Compost Facility ❑ Sludge/Ash Site <br /> Process/Recycle Facility ❑ CIA Landfill Si e <br /> ❑ Refuse Vehicles--Numbcr of Units ❑ Dumpsters>20 cu yd ----Numbcr of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ I alm/Incal � Site <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator PP GGinite ��VJJ <br /> ❑ Transfer Station ❑ VeterinaryClinic * imitcd <br /> ❑ COInnion Storage Facility----112- 10-------❑ 11 -60------❑ > rf <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS <br /> EH00(91JlrreA)nlrcarion Form GO ggne ors <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM J� JOPQ�NSE�N��S��N <br /> �C CONTACT PERSON QP ��N P`*E v <br /> �'1tLiT� f i&ay Ph Night Ph pNM <br /> PROGRAM ELEMENT /� �S FEE 2 <br /> ❑ Surcharge Fre 11 Other FEE <br /> INSPECTOR# 3 2 j PERMIT VALID �—i bD <br /> ('t�� to_ j t(D�_ 13 Food Ilandlcr <br /> u Check# AMOUNT PAID `� D�• —Z <br /> Date —( INVOICE <br /> ❑ Cash RLvILweD BY �� �r'-JoU ACCOUNTING OFI'ICt <br /> EFI 0069 PINK FORM.doc Date <br />