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SA,N JOAQUIN COUNT)IF6NVIROt�i�i IENTAL HEALTH DI��O`i <br /> MASTERFILE RECORD INFORMATION FOReMEH 0 69) .1. <br /> EH Pro and New Fact 1 <br /> at Existin Facilitv <br /> New EH Pro /ry 0 <br /> FaNei R COa 1 D- Program Record ID IC D <br /> 6 <br /> Facility Address ( <br /> (Please Check the appropriate description and specify ,number its and Pertinent information.) <br /> s! <br /> FOOD PROGRAM(1600) Square Footage �— Food Handlers Course renuired: Yu❑ No ❑ <br /> ❑Restaurant: Seating Capacity 4 ❑Vending Machines-Number of Units <br /> ❑ Commissary ❑ Dry storage only <br /> ❑ with Food Preparation <br /> ❑ Retail Market--Square footage ❑ "^�Meat Markel only ❑ Multiple Departments ❑ Prepackaged Goads Only <br /> Vehicle Type Color <br /> Cl Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Vehicle Type Color <br /> C3 Mobile Food Prep Unit-Make License# Sticker# �— <br /> Registration# to C1 ice Plant <br /> C3 Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from <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) <br /> H'A' <br /> .�RDOUS WASTE PROGRAM(2200) <br /> azardous Waste Generator-----------------Tons Generated Per Year <br /> tered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <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)PROGRAM(2300)Use UST A and B farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Housitt/Labor Camp Aoolication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPIJSEP 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 Poot/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ 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 /> ❑ Landfill ❑ Traysfer 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 Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care Cl 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 EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT -Z FEE ❑ Surcharge FEE ❑ Other FEE <br /> LVSPECTOR# PERMIT VALID ��'/ to -2 lal ❑ Food Handler. <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY 10/ CCOUN[ING OFFICE Date a a 6 <br /> EH 0069 PINK FORM.docRev.07/07/99 <br />