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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFME RECORD INFORMATION FORM(EH 00 69) <br /> XNew EH Program at Existing Facility <br /> ❑New EH Pros=and New FecilI <br /> Facili ID Program Record ED 4✓t <br /> Facility Address 44C? &aZWA a'A 9,W <br /> (Please Check the appropriate description and specify size•number of units and pertinent Information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: Yrs❑ No ❑ <br /> ❑ Restaurant: Searing Capacity Square Footage <br /> ❑ Commissary ❑ Dry storage only 130 Pre with Food Preparation ❑Vending Machines—NuUnits <br /> El Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments repackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle—Make License# Sticker# <br /> Registration# Color <br /> ❑ Mobile Food Prep Unit—Make Vehicle TypeLicense# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Daces of operation from <br /> to <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 PROGRAiv1(2200) Tons Generated Per Year <br /> Hazardous Waste Generator--------- <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Permit B Conditionally <br /> lRuExempt Household Hazardous Waste <br /> ❑ permit-By-Rule Fixed Unit y' <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(ASI)(2390)—Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jailor Exempt Institution--Number of Units <br /> ❑ Hotelliviotel-----Number of Units <br /> Employee Housing(2700) Use£ma/avee Hm<tia^/LChar Cama%ta0lirgnart Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El UIC Site <br /> ElEnvironmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site [2NPL/SEP Cleanup Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa <br /> Natural Bathing Area <br /> Number of POOWSpas at Facility ❑ Pool 11 spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> Cl Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM)(4100) [3 Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing O <br /> LIQUID WASTE PROGRAM(4200) License# CaPacCapacity Vehicle# <br /> ❑ PumperVehicle—Registration# <br /> ❑ package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> [I Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> El Landfill 11 Transfer Station ❑Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> 11 Proctss/Recycle Facility <br /> ❑ Waste Tire Facility [3 Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Unirs <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑Skilled Nursing ❑ Large Generator ❑ '- 10 [3 11 -60-13>60 generators <br /> ❑ Transfer Station 11 Veterinary Clinic ❑ Common Storage Facility <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Aoptiration Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON <br /> FEE ❑Surcharge FEE ❑ Other FEE ------ � <br /> PROGRAM ELEMENT Z?y� to I a I3 1 I U� ❑Food Handier , <br /> INDate SPECTOR# PERMIT VALID �/ 5 INVOICE#OIO <br /> �umOU <br /> ❑Check p Zs er <br /> Mta <br /> NT PAID �� ' <br /> p <br /> ❑ Cash REVIEWED BY AGCOUhG OFFICE Date II <br /> Rev.07107f <br />