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SPIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERYME RECORD LYFORtYLATION FORM(EH 00 69) <br /> ID New EH Program at Existing Facilitv ❑New EH Program and New Facility <br /> Facility ID FA CIC G 3 7 q Program Record ID <br /> Facility Address t55 7D A t c�- yy-- <br /> (Please Check the appropriate description and specify�ie number of units and pertinent information.) - <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Searing Capacity -- - Square Footage _Food Handlers Course required: Yrs❑ No ❑ <br /> 11 Commissary ❑ Dry storage only 11 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 /> Regisrration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event - Daresofoperation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) - <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser y—�Nu_m'b"er of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) I] Z-21-7 <br /> "I'P �IA�ViCe <br /> HAZARD.OUS WASTE PROGRAM(2200) " J <br /> S Hazardous Waste Generator--------------Tons Generated Per Year S s <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 A 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/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) E <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site f <br /> ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site ((' <br /> RECREATIONAL HEALTH PROGRAM(3600) 1 <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> 1 <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) t - - <br /> ❑ 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 Cleanup 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—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application form <br /> i <br /> EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM - <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGR,%4MELEFIENT 22-- FEE ❑Surcharge FE--- ❑ Other FEE <br /> INSPECfOR# R 8 4 L 4 PERMIT VALID to ❑ Food Handler � <br /> ❑ Check# AMOUNT PAID - Date - INVOICE# <br /> 0 Cash REVIEWED BY ACCoUNfnaG OFFICE Date - <br />