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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> - MASTERFILE RECORD L tFORINL4TION FORM(EH 00 69) <br /> ❑ New EH Progarri at Existing Facility C1 New EH Program and New Facility <br /> Facili LD O (L{ (,rZ, Program Record ID � �Lo L�( <br /> Facility Address N*Z.�Q— F-OA� ct!' <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage _Food Handlers Course required: YFS El No C1 <br /> El Searing Capacity Square g ❑Veudin Machines—Number of Units <br /> ❑ Commissary 11 Dry storage only C1 with Food Preparation g <br /> C3 Retail Market--Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle--Make Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to C1Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to C3Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy C1 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> l`L,kZARDOUS WASTE PROGRAM(2200) <br /> C1 Hazardous Waste Generator---------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) Condition0 Permit B aUy Exempt Ru e Household Hazardous Waste <br /> C] Permit-By-RuleFixed Unit y- <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 /> ❑ Jail or Exempt institution Number of Units <br /> C3 HoteVivlotel-------Number of Units <br /> Employee Housing(2700) Use Employee HousinglLahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1 UST-CAP Site ❑ Local My Cleanup Site C1NPL/SEP Cleanup Site C1 UIC Site <br /> ❑ Water Quality Remediation Site <br /> C1 Abandoned HW Site C1non-NPLJSEP Cleanup Site C3RWQCB Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) [1 Natural Bathing Area <br /> ClPool ❑ Spa C] Out of Service PooUSpa <br /> Number of Pools/Spas at Facility , <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—' Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> El Pumper Vehicle—Registration# <br /> License# <br /> C1 Pumper Yard <br /> ❑ Package Treatment Plant C1 Chemical Toilets—Number oEUnits <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill C1 Transfer Station C1 Ag/Cannery Waste Site C1 Proces [:1 CIA Landfill Site <br /> s/Recycle Facility <br /> ❑ Waste Tire Facility C1 Compost Facility �1 Farm/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units C1 Dumpsters>20 cu yd—Number of Units_ <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> C1 Primary Care ❑ Acute Care ❑ Skilled Nursing C1 Large Generator 11 Common Storage Facility —❑ '-- 10 ❑ it -60--❑>60 generators <br /> 11 Transfer Station C1 Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> ❑ Surcharge FEE_ ❑ Other FEE <br /> PROGPUIM ELEhIENT - FEE ❑Food Handler�� <br /> MIT VALID to <br /> htst'ecroR# � PERjIWO[CE# = <br /> ❑ Check# ANLOUNT PAID Date <br /> ACCOuMING OFFICE 2� Date <br /> 0 Cash REVIEWED BY Rev.07/07199 <br />