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SAN JOAQUIN COUNTY ENVIRONXENTAI HEALTH DIVISION <br /> MASTERFrLE RECORD INFO RtbL4TION FORM(EH 00 69) <br /> ZrNew EH Program at Existing Facilitv ❑New EH Prograum and New Facility <br /> Facility IA 06 Program Record ED 10ko5I q o 71 <br /> A V1 41.E - ��41MSCA <br /> Facility Address �- <br /> (Please Check the appropriate description and specify size•number of units and�rtinent information.) <br /> FOOD PROGRAM(1600) <br /> Footage _Food Handlers Course required: Yrs C1 No ❑ <br /> ❑ Restaurant: Searing Capacity - Square g ❑Vendin Machines—Number of Units - <br /> ❑ Commissary El Dry storage only 11 with Food Preparation _ g <br /> ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> [J Retail Market---Square footage ❑with Meat Market only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type ColorLicense# Sticker# <br /> Registration# Color <br /> C] Mobile Food Prep Unit--Make Vehicle Type <br /> License# Sticker# <br /> Registration# ❑ Ice Plant <br /> ❑ Temporary Food Facility--Dates of operation from 1O <br /> ❑ Special Event - Dates of operation from <br /> to 11 Produce Stand <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 PROGRAM(2200) Tons Generated Per Year .� T(>/l/.� <br /> Hazardous Waste Generator--------------- <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Aute Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STORAGE TAI`IK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ HoteVMotel------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use£mplavee Housin^/LaAor Camp Aoa(itatian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> C1 Environmental Assessment ❑ UST-CAP Site [I Local MY Cleanup Site ❑ NPL:sEP Cleanup Site El 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 Pools/Spas at Facility Cl Pool ❑Spa <br /> ❑ Out of Service Pool/Spa ❑ 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(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Ca aci Vehicle# <br /> ❑ Pumper Vehicle—Registration# License#. P ty <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—NumberofUnits <br /> �— <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill [I Transfer Station El Ar/Cannery Waste Site ❑ CIA LandCdl Site <br /> 13Process/Recycle Facility <br /> ❑ Waste Tire Facility [I Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ small Generator ❑ Limited Hauler <br /> ❑ Primary Care LJ Acute Care ❑ Skilled Nursing C1 Large Generator ❑ I t-60 ❑>60 generators <br /> [J Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—❑ 2- 10— <br /> -- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph �i3 �) Night Ph <br /> CONTACT PERSON <br /> �9t�AT{�D ❑SurchargeFeE ❑ Other FEE <br /> PROGRAM ELEMENT FEE y9.— ❑Food Handler�� <br /> �1 _ PERMIT VALID�— to <br /> IrtSPECfOR# 'f Date IrfVOtCE# — <br /> ❑ Check# IM <br /> AOUNT PAID �— Date t <br /> [I Cash REVIEWED BY <br /> Arrnii rNGOFFiCE �y puv <br />