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S <br /> SAN JOAQUIN COUNTY MVIRONMENTAL HEALTH DIVIS N <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑New EH Program at Existing Facility 00-7101 ❑New EH Program' <br /> and New Facili <br /> Facilit ID - �� . � <br /> Pro ram`Record ID O / <br /> Facility Address 9999 S. Austin Road <br /> (Please Check the appropriate description and specify size•number 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 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 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 /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <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 forn+s <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Cain 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(4000) PAYMENT <br /> ❑ Poultry Farm Maximum number of birds RECF I\/F r7 1:1 Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(410 ' JU� " -�� <br /> ', 6 J;'" <br /> El Tattooing(412 1) 1:1 Body Piercing(4120) <br /> �� ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) SAN JOA(" <br /> ❑ Pumper Vehicle--Registration# License# poi hgiPUBLIC p wfirr\.NES <br /> Capacity— N Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer.Station XFcAl"Ag/Cannery Waste Site 1:1SludgelAsh Site <br /> 11Waste Tire Facility ElCompost 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(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----132- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blrre Application Forts <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Kevin Basso Day Ph 209-566-5192 Night Ph209-481-1763 <br /> PROGRAM ELEMENT* FEE, t C ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# l�dD D PERMIT VALID "t D I to ' J� 10 ❑ Food Handler <br /> -Check# IIP(p AMOUNT PAID �� Date III LP l O(' INVOICE# Fpt/ <br /> o 116):-1 Cash REvIEWED BY ACCOUNTING OFFICE Date d 711 O D i <br />