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SAN JOAQUIN COUN NVIRONMI ENTAL HEALTH DIN KION <br /> MASTERFILE RECORD INFMMI ATIOIY FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilitytt ID 00 1 2 �o-1 Program Record IDp-0-61 a 0d <br /> Facility Address l Z D F r Ant,, UUo.�, <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs 11 No C1 <br /> C3Commissary C1 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 <br /> to ❑ Ice Plant <br /> ❑ Special Event - Dates of operation from <br /> to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> C3 Grade A Dairy C3 Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ' Hazardous Waste Generator-----------------------Tons Generated Per Year ` 7 <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 /> ❑ HoteUivlotel-------Number of Units C1 Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housi'alLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTIONICONTROL(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 11 Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> C1 fennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) [1 Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle—Registration# License# Capacity ------ <br /> ❑ Pumper Yard ❑ Package Treatment Plant C1Chemical Toilets Number of Units <br /> i <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash e/Ash Site <br /> ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site g <br /> ❑ Process/Recycle cle Facili ❑ CIA Landfill Site <br /> ❑ Waste Tire Facility ❑ Compost Facility y Facility <br /> ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler, <br /> ❑ Common Storage Facility ❑ 2- 10--❑ 11 -60—❑>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic b �'-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E 10069 Blue Application Form - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Eco'%— �A Pn or, I _ Day Ph q((o 3%(o —3-71 G Night Ph <br /> PROGRAM ELEMENT ZZ 2 Q FEE ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ICAIt7 PERMIT VALID::� 0Z to _lz� f D2 ❑ Food Handler___, <br /> ❑ Check# AIMOUNT PAID Date INVOICE# DG J!yg 29 — <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date $ 0.2 <br /> Rev.07/07/99 <br /> EH 0069 PINK FORM.doc <br />