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y I �11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 00 6.9 Cj vQ <br /> ❑New EH Program at Existing Facility <br /> ❑New EH Aro ram and New Facile ! <br /> Facilit ID`'' <br /> Pro rant Record <br /> Facility Address Li O Ca.\ • a m S 5 c l� �a n cl 53 59 h <br /> (Please Check the appropriate description and specify sire,number of units and Iertinent.information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEs <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Oven'ding Machines--Number of Units <br /> ❑ Retail Market----Square footage ❑ with Mcat 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) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser=--Numbcr of Containers in Multi-Head Unit <br /> CUPA ❑ State I+aciI4 Surcharge(2399) <br /> HAZARDOUS WASTE,PROGRAM(2200) <br /> ❑ IAazardous Waste Generator-----------------------Tons Generated PerYear PAYMFUT <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ ConditiorBFyyQ�WEJOE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Pemit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANI{FACILITY(AST)(2390)----Number of AST JUN 0 7 2001 <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and Blbrms <br /> HOUSING PROGRAM(2400) SAN JOAQUIN COUNTYPUBLIC HEALIN SERVICES <br /> ENVIRVNMEIIAI.VIA IV <br /> 11 Hotel/Motel-------Numbcr of Units ❑ Jail or Exempt Institu ion u � I nits <br /> Employee Housing(2700) Use Employee Housing/Labor Camp Application Form <br /> 5 E MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ap�znvironmcntal Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP 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 ❑ Out of;Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Paultry 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 Vchicle--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 Wasie Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Proccss/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Numbcr of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--LE] 2- 10-------011 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Forge <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> —� CONTACT PERSON_ cJGt McD 613 <br /> Gee Z,-Z��Q� Day Ph 2-0q S Z 7 51 S /Night Ph .5c-2- '5 <br /> PROCitAM ELEMENT_"�� FEE '�P`� ❑ Surcharge FEC 13Other FEE <br /> INSPECTOR# rL PERMII VALIDto° ❑ Food Handler <br /> )21"anck# l a E AMOUNT F,-TD t!p�. 6�� Date ,- INVOICE# ©O 8S74f0 <br /> 71 Cash REVIEWED 13Y: ACCOUNTING OFFICE Date <br />