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SAN JOAQUIN COUNTY __4 VIRONMENTAL HEALTH DMS_-,N <br /> MASTERFIL RECORD INFORMATION FORINI(EH 00 69) � � Ler- <br /> '� <br /> Ny Fr- <br /> ew EH Pro am at Existin Fa ility ❑New EH Pro am and New Facility 5 ` a � <br /> Facility ID U S �� Program Record ID F,`;) (J'3 �`� <br /> Facility Address) �� C << �� NOV 41 <br /> (Please Check the appropriate descri tion and specify size,numbe ot units and pertinent information.) E1NV,.1-i01VP✓1EN i HL HEALTH <br /> FOOD PROGRAM(1600) PERM IT/SE--VICES <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage oily ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footagc ❑ 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-----D tes of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dates of operati n from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy Grade B Dairy ❑ Milk Dispenser--Number of Containers in MuI -Head Unit <br /> /� Qwtd- r lya �, � Pt�r 5C4-t&4,5 -P j e� a Qo <br /> COPA C1 State Facility Surcharge(2399) "`'T <br /> HAZARDOUS WASTE PROGRAM or--) ��1 } ww4 0-(; <br /> , ,�J �/� <br /> azardous Waste Generator----------------'------Tons Generated Per Year �lX <br /> Tiered Permitting Faci ity ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazar ous Waste <br /> ❑ ABOVEGROUND STO GE 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 Number of Units <br /> Employee Housing(2700) Use Em to ee HousinelLabor 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 Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing area <br /> VECTOR CONTROL PROGRAM 000) <br /> ❑ Poultry Farm----Maximum n imber 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(420 <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 ❑ Tra isfer 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 Uni is ❑ Dumpsters>20 cu yd---Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(45 0) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterina Clinic ❑ Common Storage Facility ----❑ _- 10---❑ 11 -60------C1 >60 generators <br /> PUBLIC WATER SYSTEM PROG 1AM(4600) Use PWS EH0069 Blue Application Form <br /> EAIERGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON t C�= r S b, /f Dav Ph�L)?0 3 S` VC�J�" Might Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> I <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AM UNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BYACCOUNTING OFFICE Date <br /> EH 0069 PINK FORM.doc Rev.07/07/99 <br />