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S AIN JOAPUIN COUNTY ENVIRONMENTAL HEALTH DI SION <br /> NLASTERFILE RECORD INFORVIP.TION FORM(EH 00 69) <br /> XNL ew EH Program at Existing Facility ❑New EH Program and New Facilitv <br /> Facili ID 'F#,000(054LA Program Record ID 05/[e 4l7 <br /> FacilityAddress 11 WOn 12oaA F L0AA'S?P <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— El with Meat Market only ElMultiple 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 /> ❑ Petmit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> :2,-ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST 1 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and 8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hote[/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units _ <br /> Employee Housing(2700) Use Employee Housin.-Aahor Camp 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 Cl Pool Cl Spa ❑ Out of Service Poouspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds C1 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# CapacityVehicle# <br /> ❑ Pumper Yard —ff Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill C1 Transfer Station 13 Ag/Cannery Waste Site C1 SludgelAsh 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 /> 1:1Transfer Station 13Veterinary Clinic ❑ Common Storage Facility —112- 10-11 1 l -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSONrr]] Day Ph Night Ph <br /> PROGRAM ELENIENT ja FEE [] Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# A! PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE L6 Date O 13ILZ <br /> Rev.07/071,99 <br /> EH 0069 PNK FORIK.doc <br />