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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD LNFOluNIATION FORNI(EH 00 69) <br /> New EH Pro am at Existing Facility ❑New EH Pro am and New Facility <br /> CFa�cililD Program Record ID ��� ,- D� <br /> Facility Address -Sl H N� ,g^�.�rf�'°� SL <br /> (Please Check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: ves C3 No 11 <br /> luare Restaurant: Seating Capacity q g ❑Vendin Machines—Number of Units <br /> C3 Commissary C1 Dry storage only C3 with Food Preparation g <br /> C1 Retail Market----Square footage C3 with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> C1 Mobile Food Vehicle---Make License# Sticker <br /> Registration:. <br /> C1 Mobile <br /> Type Color Mobile Food Prep Unit—Make License# Sticker# <br /> Registration# ❑ Ice Plant <br /> [Ito Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> to <br /> DAIRY PROGRAM (2000) <br /> [1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy C3 Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) !�'"S n <br /> HAZARDOUS WASTE PROGR�iVi(2200) <br /> , <br /> XrHazardous Waste Generator---------------------orized Tons Generated Per Year <br /> Tieredly Exempt <br /> Permitting Facility uth <br /> C3 P°�°By Rully le Fixed UnitCA) ❑ Permit By_1Ru e Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STOP-AGE THINK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C] Hotel/1lotel-------Number of Units <br /> Employee Housing(2700) Use Employee Housin WLabor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site C3 Local HW Cleanup Site C1NPL/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) C3 out of Service Pool/Spa C3 Natural Bathing Area <br /> Number of PooWSpas at Facility EJ Pool <br /> C1 Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) C] Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle—Registration# License P tY <br /> C] Pumper Yard C1 Package Treatment Plant El Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) g [ISludge/Ash Site <br /> C3 Landfill C1 Transfer ?� /Cannery Waste Site Transfer Station ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Farm/Rauch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care El Skilled Nursing ❑ Large Generator C1 Small Generator ❑ Limited Hauler <br /> [:1 Common Storage Facility --❑ '-- IO <br /> ❑ 1 l -60—❑>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON t S Tt U DT Day Ph <br /> I0t— 5-yq(0 Night Ph <br /> FEE v 00 A Surcharge EE 7• sy ElOther FEE <br /> PROGRA,NtELEprIENT 722 ,P!-D ❑ Food Handler_ <br /> INSPECTOR# T9.l_ PERMIT VALID t0 i <br /> ❑ Check# ,rI <br /> AOU�IT PAID Date INVOICE# 3- <br /> ACCOUNTING OFFICE Date (IZ.❑ Cash REVIEtiVED BY Rev.07/07/99 <br /> Fu nmg PINI:FORIM.doc <br />