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SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI TON <br /> MASTERFrLE RECORD INFORMATION FORM(EH 00 69) <br /> New EH Pro at Existing ❑New EH Program and New Facili <br /> FacilityH) DCS O Program Record ED <br /> Facility Address SD 'R W <br /> (Please Check the appropriate description and specify size•number of units and°erttnent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:Units ❑ N° ❑ _ <br /> ing Machines <br /> ❑ Commissary [] Dry storage only ❑ with Food Preparation Meat Market only ❑VMullttip a Departments—Number❑ Pep Prepackaged Goods Only <br /> ❑ Retail Market—Square footage Color. <br /> ❑ Mobile Food Vehicle---Make Vehicle Type <br /> Registration# License# Sticker# <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit-Make License# Sticker# <br /> Registration# <br /> to 11 Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from C3 Produce Stand <br /> ❑ Special Event -Dates of operation from Lo <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 /> FLA2ARDOUS WASTE PROGRAM(?'00) --Tons Generated Per Year <br /> Hazardous Waste Generator------------------ <br /> ly Exempt <br /> Tiered Permitting Facility 0 Conditionally ueFixed Uniuthorized t ❑ 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 E forms <br /> HOUSING pRoGRAM(2400) <br /> ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Emoloyee Nousin/Lahor Ca,o Aonfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ClUST-CAP Site ❑ Local HW Cleanup Site ❑ NPLlSEP Cleanup Site [3 UIC Site <br /> ❑ Abandoned HW Site ❑ uon-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> El Natural Bathing Area <br /> Number of PooWSpas at Facility ❑ Pool Cl spa ❑ Out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> C3 Pumper Vehicle-Registration# License# P ry <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units�— <br /> SOLID WASTE PROGRAM(4400) ❑A /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station g ry Facility ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facty <br /> C3 Waste Tire Facility ❑ Compost Facility ❑ FarmtRauch Cleanup Site <br /> 1:1 Refuse Vehicles-Number of Units 13Dumpsters>20 cu yd—Number of Units - <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—❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS ghm Bia� Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON >l+�I ^ Jr-r- JQ 1 �1 I Day Ph ({�1S-3�t'tD Night Ph <br /> PROGRAM ELEMENT? Z C) _ FEE 7 �0� •6V _. ❑ Sureharge FEE [I Other FEE � <br /> PERMIT VALID�— to <br /> ❑ Food Handler <br /> INSPECTOR# INVOICE# ©O <br /> ANOINT PAID �— Date <br /> ❑ Check# Date 7 <br /> ❑ Cash REVIEWED BY AccouNTTNG OFFICE <br /> Rev.07!07!99 <br /> EH 69 PINK FORM.doc <br />