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L!n <br /> JOAQUIN COUNTY�VIRONMENTAL HEALTH DIVISW <br /> MASTERFILE REC INFORNIATION FORM(EH 00 69) <br /> ❑New EH Program at ExistingFacili OUT]�'-{ ��(� ❑New EH Pro ram and New Facilit <br /> Facilit ID Pro ram Record ID <br /> Facility Address /S <br /> (Please Check the appropriate description and specify size number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation - ❑Vending Machines—Number of Units <br /> ❑ Retail Market----Square footage— El with Meat Market only ❑ Multiple Departments ElPrepackaged Goods Only <br /> 11Mobile 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) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> — <br /> CUP ❑ State Facility Surcharge(2399) _ <br /> HAZAJIDOUS WASTE PROGRAM(2200) rExempt <br /> Hazardous Waste Generator----------Tons Generated Per Year L VI'h ❑ Recycle/Exempt System <br /> I red Permitting Facility ❑ Conditionally Authorized(CACondition l (CE) <br /> 11 Permit Fixed Unit ❑ Permit-B -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 forms <br /> HOUSING_ PROGRAM(2400) <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned [IW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm---Maximum number of birds - ❑ 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) <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 /> ❑ Transfers Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 10-------❑ 11 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIFS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON z Day Ph - Night Ph <br /> PROGRAM ELE t N X63 V1 FEE � <�� � ❑ Surcharge EE 11 Other FEE <br /> INSPECTOR# - — ERMIT VALID ❑ Food Handler y <br /> ❑ Check# AMOUNT PAID Date INVOICE# 13 1" '1 <br /> ❑ Cash REVIEWEDBY ACCOUNTING OFFICE `.. > Date 'fl <br /> EH 0069 Pink Form Rev.0225/03 <br />