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SAIN JOAQUIN COUNTY ENVIRONMENTAL:HEALTH DIVISION <br /> MASTERFELE RECORD 111FOR114A.TION FORM(EH 00 69) <br /> New EH Program at Existing Facility ❑New EH Prop and New Facility <br /> Facility ID () db SFJ 3o Program Record ID I a �( 3 a3 <br /> Z <br /> r P <br /> Facility Address 13 3 3 �> D- I'P- o sl8 3a y( � <br /> (Please Check the appropriate description and specify size• number of units and Pertinent information.) - <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing CapacitySquare Footage Food Handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑ 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 to ❑ Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) C2,,C <br /> ❑ Grade A Dairy ❑ Grade B Dairy ZZI1❑ Milk Dispeuser—Number of <br /> Containers in Multi-Head Unit <br /> COPA 11 State Facility Surcharge(2399) - 22 1-7 A pP 114 e- j9 -y0L1 <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous 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 A and B forms - <br /> HOUSING PROGRAM(2400) <br /> ❑ <br /> C1 HoteVl4lotel-----Number of Units Jailor Exempt Institution—Number of Units <br /> Employee Housing(2700)Use E plow^Ho tsin/Labor Cama Application Form <br /> SITE MITIGATION(2900) uNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1 UST-CAP Site ❑ Local HW Cleanup Site 11NPLIS_EP Cleanup Site ❑ UIC Site <br /> ❑ .Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ElRWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSoas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Fennel <br /> ❑ Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ permanent Cosmetics(4122) <br /> C1 Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> ❑ Pumper Vehicle-Registration# License# Capacity <br /> ❑ Pumper Yard. ❑ Package Treatment Plant ❑ Chemical Toilets—•Number of Units <br /> r <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑TmnsferStation ❑Ag/CanneryWas[eSt[e <br /> ❑ Process/Recy ty cle Facility [I CIA Landfill Site <br /> ❑ Waste Tire Facility [3 Compost Facility 13 <br /> Farm/Ranch 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 ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> 13 Transfer Station ❑ Veterinary Clinic <br /> ❑ Common Storage Facility —❑2- to—❑ it -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form - <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON A(lrs5 Day Ph l 61 - [z 1`1 Night Ph <br /> PROGRAM ELENIENT ZG D 2212 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 11,12 — PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> [I Cash REvrEVED BY <br /> ACCOUN rNG OFFICE Date �/ 3 D�' <br /> Rev.07/07/99 <br />