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SAIN JOAQUIN COUNT ZNVIRONMENTAL HEALTH DIV aaION <br /> MASTERFILE RECORD INFORMATION FORM(EH 00 69) <br /> New EH ProeTarn at Existing Facility ❑New EH Progain and New Facility <br /> Facili ID 00 02- Program Record ID R �J�3o2 <br /> Facility Address 35 (J C I I/\e rD VA Ct LK) , Lon, C!k <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Searing Capacity Square Footage OVe Handlers Course required: Yes❑ No 11C1 <br /> Commissary 11 Dry storage only 11 with Food Preparation Vending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Color T <br /> Type El Mobile Food Vehicle—Make VehicleSticker# <br /> Registration# License# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Color <br /> Type Sticker# <br /> Registration# License <br /> to C1 Ice Plant <br /> [] Temporary Food Facility--Dates of operation from 11 Produce Stand <br /> C3Special Event - Dates of operation from f0 <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) / 1 <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year l Z 7-20 1 <br /> ' (Hazardous Waste Generator------- — ----Tons <br /> 0 Conditionally Exempt <br /> Tiered Permitting Facility ElPermit By Conditionally <br /> e Fixed UnitCA, ❑ Permit-By-Rue Hous hold 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 /> ❑ jail or Exempt Institution—Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee F[ousing(2700)Use Emplavee Housin/L,,or Camp,4 ticaBop Form - <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment C1 UST-CAP Site ❑ Local HW Cleanup Site LlNPL/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) ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility Cl Pool 13 Spa ❑ Out of Service 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(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> C1 Pumper Vehicle—Registration# License# . P tY <br /> C1 Pumper Yard <br /> [J Package Treatment Plant IJChemical Toilets—Number of Units <br /> _ <br /> i <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste litre <br /> ❑ Waste Tire Facility [3 Compost Facility ❑ ProcesslRecyNucle Facility <br /> ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 to yd—Number of Units <br /> C] FaruilRnnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Small Generator 11 Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2- 10 ❑ l l -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Farm <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> �7��Z FEE ❑ Surcha eFE [3 Other FEE <br /> PROGRAbt ELEMENT G Z <br /> 1 '( PERMIT VALID / / 2 t0 /or{ 3r O ❑ FOOd Handler�� <br /> IYSPECTOR# INVOICE# y S3 <br /> AMOUNT �— Date <br /> 13 Check# T PAID Date Q2 <br /> ❑ Cash REVIEWED BY ACCOIMrtNG OFFICE <br /> Rev.07/07199 <br /> EH 0069 PINK FORM.doc <br />