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SAN JOAQUIN COUNTY ENVIRONMENTAL;HEALTH DIVISION <br /> MASTERFILE RECORD INFORINIATION FORM(EH 00 69) <br /> New EH Pro at Existing Facility ❑New EH Pro and New Facili <br /> o5a) 5-79 <br /> FFacility ID FAC o0o U`lL16 Program Record ED <br /> FacilityAddress <br /> 2315 _ Yy6fk-I_ B1 v� 'Trach C!� �153T(o <br /> (Please Check the appropriate description and specify s6 number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage Food Handlers Course required: Yes 13 NO 11❑Restaurant: Searing Capacity - Square g ❑Vendin Machines—Number of Units <br /> ❑ Commissary 11 Dry storage only C3 with Food Preparation g <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type <br /> License# Sticker# <br /> Registration# to El Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ produce Stand <br /> ClSpecial Event -Dates of operation from L0 <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Unit <br /> — <br /> CUP ❑ State Facility Surcharge(2399) <br /> FLaZr,RDOUS WASTE PROGRAM(2200) 22�v ons Generated Per Year �-5 Tdns <br /> Jd`a" HTiered Permitting Facility azardous Waste Generator----- — — — ❑ Conditionally Exempt t CE) <br /> ❑ Conditionally Authorized(CA) <br /> ❑Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> IJ 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 /> ❑ Jail or Exempt Institution—Number of Units <br /> 1:1 HoteVMotel-------Number of Units <br /> Employee Housing(2700)Use Emvloyee H sir/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site El Local IIW Cleanup Site ❑ NPLJSEP 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 pooWSpas at Facility ❑ Pool ❑ Spa <br /> C1 out of Service Pool/Spa <br /> ❑ Natural Bathing Area <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 /> ❑ Pumper Vehicle—Registration# License# P tY <br /> ❑ Pumper Yard <br /> ❑ Package Treatment Plant 13Chemical Toilets—Number of Units�— <br /> - <br /> SOLID WASTE PROGRAM(4400) ❑p /Cannery Waste Site ❑ sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station g El CIA Landfill Site <br /> ❑ Waste Tire Facility [I Compost Facility ❑ Process/Recycle Facility ❑ Farmanc <br /> Rh Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units . <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care LJ Skilled Nursing ❑ Large Generator El Small❑ 11erat r❑ >i60 generatorsHauler <br /> 11 Transfer Station C1 Veterinary Clinic [I common Storage Facility -9-0 2- 10— <br /> 60 <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> 13Surcharge •EE�' C1 Other FEE <br /> PROGRAM ELEh1E/NT`�, �� FEE —�D� t y51 pf 3 [I Food Handler_ <br /> INSPECTOR# �`�l PERMrr VALID t0 <br /> Date INVOICE# ' <br /> ElChcck# AMOUNT PAID Date <br /> ❑ Cash REVIEWED BY ACCOUNnNG OFFICE <br /> Rev.07/07/99 <br />