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SAN JOAQUIN COUNT1 e NVIRONl1ENTAL HEALTH DIVIOtON <br />MASTERFILE RECORD LNFORVL-kTIOiN FORv1(EH 00 69) <br />New EH Progrartl`at Existing Facility ❑New EH Program apd New Facility <br />Facility ID 0 ) V I A'A 7-/I Program Record ID v) L "J /O L/ I <br />Facility Address 10 U 1:21t2 iJL.4y_4- 'r Vr <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />NOV 5199.9 <br />ENVJR0Ni 1&'41,11_ HEALTH <br />PERMIT/SERVICES <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 <br />❑ Special Event - Dates of operation from to <br />❑ Ice Plant <br />❑ 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 />Cl 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 Bforms <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units C3 Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Flousing/Lahor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />El Environmental Assessment C1UST-CAPSite C1 Local HW Cleanup Site C1NPL/SEP Cleanup Site [3 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 Cl Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds <br />❑ Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ 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 C1 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 C1 Acute Care El Skilled Nursing ❑ Large Generator C1 Small Generator [I Limited Hauler <br />C1Transfer Station [3Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 -- 1:1I 1 - 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 <br />PROGRAM ELEMENT-Qn <br />INSPECTOR # <br />❑ Check # A <br />❑ Cash REVIEWED BY <br />EH 0069 PINK FORM.doc <br />FEE <br />PERMIT VALID <br />WOUNT PAID <br />Day Ph <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />Night Ph <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # _ <br />Date I <br />Rev. 07/07/99 <br />