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SAN JOAQUIN COUNTY ENVIRONMENTAL;HEALTH DIVISION <br /> MASTERFII.E RECORD INFORIVIATION FORM(EH 00 69) <br /> ew EH Program at Existing Facility New EH Program and New Facility <br /> 'Facility ID bVilf5 of Program Record ID Q Sad 4 <br /> Facility Address IF ! r ICU'- 5 l�` r <br /> (Please Check the appropriate description and specify size-number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capaciry Square Footage Food Handlers Course required: YES 13 No 11 <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# License' Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to El Ice Plant <br /> ❑ Special Event - Dates of operation from to 13 Produce Stand <br /> DAIRY PROGRAM (2000) - <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispeoser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) - <br /> H.42ARDOUS WASTE PROGRAM(2200) � A4 <br /> WASTE <br /> *Hazardaus 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 8 farms <br /> HOUSING PROGRAM(2400) - - <br /> ❑ Hotetlivlotel------Number pf Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Ho rsin/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP site ❑ Local MY Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ` ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out or service PooUSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) [1 Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ Pumper Vehicle-Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard Cl Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) t <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Process/Re cle Facility ❑ CIA Landfill Site <br /> 11 Waste Tire Facility ❑ Compost Facility c1' h' <br /> C3Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu yd—Number of Units C1 FarmRtancft Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care 11 Acute Care ❑Skilled Nursing ❑ Large Generator [I Small Generator ❑ Limited Hauler <br /> El Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility,—❑ 2- 10—❑ I I-60--Q>fi0 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> (7 tff Day Ph Night Ph Ni . <br /> CONTACT PERSON K. Q.� I O )( <br /> r I/\ <br /> i <br /> PRoGR.i,H ELEn[FNT - <br /> FEE 2, ❑surcharg Fes ❑ Other FEE <br /> I�set:cron# ( PERMIT VALID 4 �`� D�Jto ❑Food Handler�- <br /> ❑ cheek# AHouNTPAm L+ LLAJw N Date INYolce# -b.L <br /> Cl Cash REVTEZVED BY ACCOUNTING OFFICE Date <br /> Date - - 43 <br /> Rev.07/07199 <br />