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SAINt JOAQUIN COUNTY ENVIRONMENTAL;HEALTH DIVISION <br /> MASTERFILE RECORD Pi iFORMATION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Program and New Facili <br /> ty <br /> FacilitylD 00 1 Z466 Program Record ID46. <br /> Facility Address 11�) 10 S lroIij:�& S <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare Footage _Food Handlers Course required: Yes❑. No 11 <br /> ❑ Commissary ❑ Drystorage only El 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# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from <br /> to ❑ Ice Plant <br /> 13 Special Even[ - Daces of operation from <br /> 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(399) - <br /> HAZarRDOUS WASTE PROGRAM(2200) <br /> 'UkHazardous Waste Generator-------------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 /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST,4 and 8 forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee HourinelLahor Cama Application 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 i' ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of Pools/Spas at Facility C] Pool [3 spa ❑ Out of Service PpoUSpa g <br /> VECTOR CONTROL PROGRAM(4000) [❑ Kennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> 11 Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> 11 Pumper Vehicle—Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Slud e/Ash Site <br /> 13Lnodlill El Transfer Station C3 Ag/Cannery Waste Site g <br /> ❑ Waste Tire Facility <br /> ❑ Compost Facility ❑ ProcesslRecycle Facility [3CIA Landfill Site <br /> ❑ Farm/RanchCleanupSite <br /> El Refuse Vehicles—Number of Units ❑ Dumpsters>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 EHOO69 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON C.f a�� }er5 Day Ph�i2' Night Ph <br /> PROGRAM ELEMENT Z Z 0 FEE ro r KI4,, ❑Surcha a FEE <br /> [I Other FEE <br /> p <br /> INSPECTOR# D31� PERMITVALID 1 f)2 to 17,131 oZ [3 Food Handler___ � <br /> ❑ Check# AMDIJ,tlT PAID Date INVOICE# <br /> ACCOUNTING OFFICE Date IA. /1I V <br /> Cl cash REVIEWED nY Rev.07/07/99 <br />