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` G°>3ECENED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION FEB 2 2 2002 <br /> MASTTRFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑ New EH Program at Existin Facility ENew EH Pro ram and New Facility ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> �FacilitX ID Pro rani Record ID 51 OZ3 <br /> Facility Address '-3'165 N. %4,,.� G%g I Fo VN,,pus °t--*W-90tCA, 9s-L"O <br /> (Please Check the appropriate description and specify size number of mots and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capaciry 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 It 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 /> CUP A ❑ State Facility Surcharge(2399) o��a O <br /> HAZARDOUS WASTE PROGRAM(2200) - <br /> Hazardous Waste Generator--------<5-----Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> AND � <br /> BOVEGROUND STORAGE TANK FACILITY(AST)(2390)---Number of AST — <br /> ERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B(onus <br /> HOUSING PROGRAM(2400) , <br /> ❑ IIotcUMotcl-------Number of Units - ❑ Jail or Exempt Institution­Numberof Units <br /> Employee Housing(2700) Use Fam/ovee Housinr/Labor Cana Aan(icarion Fonn <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-----Maxinwm number of birds ❑ Kemtel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4106) <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 11Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility F-1CompostFacility ❑ 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----02- 10-------❑ 11 -60------1:1 >60 generators <br /> PUBLIC <br /> _WATER SYSTEM PROGRAM(4600) Use PWS FH0069 Blue Application Fornl <br /> 1Wvc/Lt Pus- EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON %Aib%= Q-v Z%\\ Day Ph 4TN 3C8-h Lll Night Ph(%AA)900,- VsO9 <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNTPAID. Date INVOICE# q <br /> :1 Cash REVIEWED BY - ACCOUNTING OFFICE Date <br /> bA b.-L4 J 9390b <br />