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A1�1 JOAQUIN COUNTY'ENVIRONMENTAL HEALTH DIV rdION <br /> MASTERFILE RECORD IINFORNLATION FORM(EH 00 69) <br /> Yew EH Program at Existing Facility " ❑New EH P top=and New Facility <br /> Facility ID ©00 0 1 % :S Program Record ID <br /> Facility Address 11,:� k 7 Q C A M (Lf 4Z=. <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) - _1 <br /> ❑Restaurant: Searing CapacitySquare Footage _ Food Handlers Course required: Yrs❑ iVo ❑ <br /> C1 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 9 License# Sticker# <br /> ❑Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Dares 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 C v TONS r y rr <br /> Tiered Perrttitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) T— <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)PROGR.k vl(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housine/Lohor 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 ❑ Spa ❑ Out of service PooUspa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number ofbirds ❑ 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 /> IJ 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 Clenaup 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—❑ I I-60—❑>60 generators - <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHOO69 Stue Applicadon Form _ <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM - <br /> CONTACTPERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Z Z 2 O FEE Z00,00 - Os h <br /> efFEs ❑ Other FEE <br /> INSPECTOR# I :Z— PERMIT VALID 0 1 to -$ - ❑Food Handler_ <br /> 11 Check# - AMOUNT PAID Date - - - INVOICE# <br /> ❑Cash REvrEwEO BY ACCOUN-MG OFFICE t"C Date s U 'C% <br /> EH 0069 PINK FORA["doe - - - - - - RN.07MV99 <br />