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Y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVIS1uN <br /> MASTERFII.E RECORD INFORM .TION FORM(EH 00 69) CO ^ � <br /> New EH Pro a[ExistingFacility <br /> ❑New EH Program and New Facil[ <br /> Facili ID I Z ( Program Record ED 510��r aa� <br /> Facility Address Z251 I L&Acl—Ln ,--51t� <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Food Handlers Course required: Yrs❑ No <br /> ❑Restaurant: Searing Capacity Square Footage ❑yeodin Machines—Number of Units <br /> ❑ Commissary C3 Dry storage only . 11 with Food Preparation g <br /> El Departments ❑ Prepackaged Goods Only <br /> C3 Retail Market--Square footage C3 with Meat Market only <br /> 13 Mobile Type Color.Mobile Food Vehicle--Make License B Sticker X <br /> Registration X <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit—Make License# Sticker X <br /> Registration X ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of rC�ontainers in Multi-Head Unit <br /> COPA [I State Facility Surcharge(2399) )4,HW Q�Lyc-lines p,) 19 go 5-1(0(a a <br /> HAZARDOUS WASTE PROGRANI(-100) Tons Generated Per Year <br /> X,Hazardous Waste Generator------------- -- <br /> (CA) Conditional <br /> A) ❑ ConditionallExempt CE <br /> Tiered Permitting Facility 0Pent- yI1le <br /> Conditionally <br /> Unit <br /> ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑ Jail or Exempt Institution—Number of Units <br /> ❑ Hotel/Nlotel------Number of Units <br /> Employee Housing(2700) Use E plover H ... /Laho Camp Applicatiop Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site El UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM <br /> Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of Pools/Spas. <br /> VECTOR CONTROL PROGRAM(4000) Cl Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(41_l) <br /> 11 Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) Vehicle q <br /> C1 Pumper Vehicle—Registration K License X Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud dAsh Site <br /> ❑ Landfill ❑ Transfer Station 13 Ag/Cannery Waste Site g <br /> ❑ Process/Rec cle Facility [3 CIA Landfill Site <br /> C3 Waste Tire Facility ❑ Compost Facility Y ty ❑ Firm/Ranch Cleanup Site <br /> C3 Refuse Vehicles—Number of Units 11Dumpsters>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 /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10—❑ I 1 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFWATION FOR THIs FACILITY ANO/OR PROGRAM <br /> CONTACT PERSONDay Ph Night Ph <br /> PROGRAM ELEMENTZZ5)5 Z220 FEE 3&Ir�c !!0' — 13 Surcharge FEE ❑ Other FEE <br /> r�a� to ❑Food Handler <br /> INSPECTOR 1l t7T 1 PERMIT VALID <br /> ❑ Check p AIMOUNT ID Dale INVOICE# <br /> ACCOUNTING OFFICE Date ! <br /> n Cash REv1EwE0 BY Rev.07/01/99 <br /> FH 0069 PINK FOP-M.doc <br />