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SAM JOAQUIN COUNTY ENVIRONMENTAL=EH <br /> DIVISION <br /> MASTERFILE RECORD INFORMATION F69) <br /> ❑New EH program a[ExistingFacility <br /> ❑New Pro and New Facility <br /> Facili ID FA+ Program Record ID <br /> Facility Address -A y. r�E���F <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOODP� RoGRAM(1600) S uaze Footage <br /> ❑ Commissary ❑ Dry storage only Food Handlers Course required: YEs C1 No 13 <br /> El Seating Capacity ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑ Retail Market---Square footage ❑ with Mea[Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle---Make License d Sticker X <br /> Registration X Color <br /> Sticker <br /> C] Mobile Food Prep Unit—MakeVeLicense# <br /> hicle Type # <br /> Registration tt - to C] fee Plant <br /> ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand <br /> ❑ Special Event -Dates of operation from <br /> to <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade B Dairy ❑ Milk Dispe¢ser—Number of Containers in Multi-Head Untt <br /> C3 Grade A Dairy <br /> COPA ❑ S�tn�Facility Surcharge(2399) Lcj-NC�-+`=� <br /> FLAZ?.IjI3UUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> Hazardous Waste Generator -------------- ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Permit-B Rule 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 Jail or Exempt Institution Number of Units <br /> ElHoteU'Lvlotel-------Number of Units <br /> Employee Housing(2 MO) Use E glove Ho s7 ^/L h Camp UNDERGROUND <br /> Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTR LJSEP0) UIC site <br /> ❑ Environmental Assessment 0 UST-CAP <br /> Site <br /> Cleanup Ste Local HW leanuRWQCleanupp Site ❑Sit PVS❑PWater Quality RemeCleanup Site ❑dlat on Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Out of Service Pool/Spa C3 Natural Bathing Area <br /> Number of pooWSpas at Facility Cl Pool ❑ Spa _ <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) Capacity Vehicle ff <br /> ❑ Pumper Vehicle—Regisrmtion k License q P tY <br /> El Pacage kTreatment Plant ❑ Chemical Toilets—Number of Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ SludgetAsh Site <br /> ❑ Landfill ❑Transfer Station ❑ Ag 1 Cannery Waste lily El CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ FarmfRanch Cleanup Site <br /> El Refuse Vehicles—Number of Units 11 Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Skilled Nursing 13 Large Generator ❑ Small Generator C1 Limited Hauler <br /> ❑ Primary Care LJ Acute Care <br /> ❑ I I -60—❑>60 generators <br /> 11 Transfer Station ❑ Veterinary Clinic [I Common Storage Facility —❑ -_ 10--- <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 /> ❑ Surcharge FEE [I Other FEE <br /> PROGRAM ELEMENT� i.7 FEE ❑ Food Handler_�� <br /> PERMIT VALID Jam— to <br /> I;lSPECTOR# `iS i� jNVOICE# <br /> AMOUNT PAID - Date <br /> ❑ Checkp Date <br /> 0 Cash REVIEWED SY ACCOUNTING OFFICE Rev.07/07199 <br />