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SAN JOAQUIN COUNT NVIRONMENTAL HEALTH DI ON <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Yacili tX ID' -'1 program Record Ill Jr/7 <br /> FacilityAddress <br /> (Please Check the appropriate description and specify size,number of units and pertinent i Iforma[imL) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes 11No 1111Commissary ❑ Dry storage only [Jwith Food Preparation []vending 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---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-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 B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotcl/Motcl------Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Cantu Annlicorion Foran <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 IIW 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 PooVSpa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds - ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4106) <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 ElAg/Cannery Waste Site 13Sludge/Ash Site <br /> 13Waste Tire Facility ElCompost 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 /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----112- 10-------❑ 11 -60------El >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON r� Day Ph Night Ph <br /> PROGRAM ELEMENT ani. > d FEE ❑ Surcharge FEF ❑ Other FEE <br /> INSPECTOR# PERMrr VALID to ❑ Food Handler a <br /> Check# (( �--�—� AMOUNTPAID �w( - Date DI INVOICE# 00658 ( Lq <br /> :I Cash REVIL•wBD BY (C - ACCOUNTING OFFlCE' [ Date D' 10 <br />