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SVJOAQUIN COUNTY TI T-WIRONMENTAL HEALTH DIVISION MASTERFILE RECORD INFORMATION FORM EH 00 69 ❑New EH Pro ram at Exlstm Facih ®New EH Pro ram and New Facili 1�05a Facilit 'I Pro rain`Reenrd ID (.�a Facility Address -7/.28 D�ls7-vl'4< AelAer s7loe612" C.l, (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation []vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation ' from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ® State Facility Surcharge(2399) 1--IAZARDOUS WASTE PROGRAM(2200) r ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year < ZJ Tiered Permitting Facility IN Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑ hotel/Motel-------Number of Units ❑ Jailor Exempt Institution-----Number of Units Employee housing(2700)Use Employee Housing/Labor Cann Agglication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Clcanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4106) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity - Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----02- 10-------011 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Bitte Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph a/OB-J-77 ROW Night Ph yob- 9�8- 87s� PROGRAM ELEMENT �' _ ❑ Surcharge F>slr ❑ Other FEE INSPECTOR# PERMIT'VALID. to m , T? ❑ Food Handler ❑ Check# AMOUNT PAID , Date INVOICE# :1 Cash REVIEWEb BY ACCOUNTING OFFICE Date Eli G:69 PINK FORM.doc s Rev.07/07/99