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'e-SAN JOAQUIN COUNTY i:.r VIRONMENTAL HEALTH DIVIS,101N <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑New EH Program at Existing Facility ❑Ncw EH Program and New Facility <br /> 161it ID I a' s <br /> O ;Pro <br /> X; ram Record ID <br /> Facility Address 4496'sr 4- <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: )(Fs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vcnding 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) PAYME1V 1 <br /> ❑ p <br /> Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers" FrOcElh/cddrnit <br /> CUPA ❑ State Facility Surcharge(2399) +fir <br /> HAZARDOUS WASTE PROGRAM(2200) WA <br /> ❑ Idazardous Waste Generator-----------------------Tons Generated Per Year , , v <br /> ..Iq UOUN7YTiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exo'WN E❑ Pernzit-By-Rule Fixed Unit ❑ Permit-By-Rulemie <br /> S <br /> zIifddtimWaste <br /> ❑ ABOVEGROUND STORAGE TANK FACILI'T'Y(AST)(2390)----Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A oral R forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee]lousing(2700) Use Ern plo ee Horrsim /Labor Camp p Application Forrn <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) <br /> ❑ Poultry Farm----Maximo n number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing'(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> L RUID WASTE PROGRAM(4200) <br /> umper Vehicle--Registration# License# Capacity - Vehicle# <br /> Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer,Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost 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----❑ 2- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHOO69Blue Apatication Form <br /> / EM RGENCY NOTIF ATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON t .. Day Ph Ze2'—Z` 2 ZZ3 Night Ph _'7 y ­�- 7(�,9 ° <br /> PROGRAM ELEMENT ".FEE: � <br /> r �' �' ❑ SurclhargeFEE ', ❑ Other FEE <br /> 1rvs1 CTOR# [P PCitMI1 VALID C�31(�-1 0J to - l I3I El Food HandIcr <br /> ©Check N_ [0AMOUNTAMOUNT PAID 00 Date [J I INVOICE# <br /> 71 Cash REVIt:wEDBY: ACCOUNTING OFFICE Date 05 Ds� <br />