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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISIOtN <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑ New El I Pro gram at Existin Facili New EH Pro ram and New Facilitv <br /> Facilit 'ID eo is&a 9 Program Record ID <br /> Facility Address $1035 kUNWL_C� tD t'1 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <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 /> ❑ Mobile Food Vehicle-----Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <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 /> COPA ❑ 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution--Numbcr of Units <br /> Employee Housing(2700)Use Employee Housia /Labor Cam A r rlica;HW�Cl�eanup <br /> SITE MITIGATION(2900) NDERGRTION CONTROL(3000 03o <br /> Environmental Assessment ❑ UST-CAP Site Localite NPL/SEP CleanupSite U1C 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 Pools/Spas 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 ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/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) pm, MF�N Wap <br /> ler <br /> Care ❑ Acute Care El Skilled Nursing ❑ Large Generator El Small Generator P&a Wauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----02- 10-------❑ 1 1 -60------13>e60 enat0 <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blne Application Form SCP <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM SAN 3pAO�N SERVICE <br /> CONTACT PERSON Day Ph Night Ph PO8L1C NTp�jHEAlJH01V1S10N <br /> Pitowum ELENIENT FEE 2' ❑ Surcharge FEE ❑ Other FEE <br /> INSPE'PTOR# PERMITVALID to q / 13 Food Handler <br /> M'cheeka AMOUNTPAII) Date L-�1,-� a l.�-INVOICE# d?.5-7741 <br /> ;-1 CashRr_vlrwr n[�v ACCOUNTING OFFICE Date <br /> Eli lr1,:69 PINK FORMAoc Rev.07/07/99 <br />