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'SAN JOAQUIN COU TY VIRONNIENTAL HEALTH DIVI; N <br /> .MASTERFILE RECORD INFORMATION FORM(EH 00 69 <br /> New EH Pro am at Existin Facility ❑New/EH Program and New Facility <br /> Facility ID Q / O 3 Program Record ID r S) V3 <br /> FacilityAddress 3-3 <br /> (Please Check the appropriate descri tion and specify size,numbe 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 o ily ❑ 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 /> C3Mobile 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 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) ,�P,,- �n r l �- _ n f Q <br /> azardous Waste Generator---------------------Tons Generated Per Year v-�C� �(�/ v( <br /> Tiered Permitting Faci ity ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazar pus Waste <br /> ❑ ABOVEGROUND STOP-4 GE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAG TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Un is ❑ Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Em to ee HousinelLabor Camp 4 lication 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 Cl 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(420 0) <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 ❑ Tr2 nsfer 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(4 00) <br /> ❑ Primary Care ❑ Acute C ire ❑ Skilled Nursing ❑ Large Generator C1 Small Generator El Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ 11 -60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PRO RAM(4600)Use PWS EH0069 Blue Application Form <br /> E MERGENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON j �1 S��, __J f Day Ph ' �� 7Cf9% Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PRM IT VALID to ❑Food Handler <br /> ❑ Check# AM UNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING.OFFICE Date <br /> EH 0069 PINK FORM.doc Rev.07/07/99 <br />