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c <br />SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DI ION <br />MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br />New EH Program at Existing Facility ew EH Program and New Facility <br />Facility ID Program Record ID e), Is—_W,- <br />Facility Address 1,2 9 jno1P 0Mj Ajenue_ . +nn <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 J"f WAS <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 forms <br />HOUSING PROGRAM(2400) <br />HotellMotel-------Number of Units Jail or Exempt Institution Number of Units <br />Employee Housing(2700) Use Employee Housi relLabor Camp Application Form <br />SITE MITIGATION(2900)UNDERGROUND INJECTION CONTROL(3000) <br />Environmental Assessment UST-CAP Site Local HSV 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 Maximum number of birds Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br />Tattooing(4121) Body Piercing(4120) Permanent Cosmetics(4122) <br />LIQUID WASTE PROGRAM(4200) <br />Pumper 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 EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON DIZ Day Ph Night Ph <br />PROGRAM ELEMENT 44P FEE Surcharge FEE Other FEE <br />INSPECTOR# 014J8 PERMIT VALID to Food Handler <br />Check# Ai1-IOUNT PAID Date INVOICE# <br />Cash REVIEWED BY ACCOUNTING OFFICE Date I J ja <br />EH 0069 PINK FORM.doc <br />Rev.07/07/99