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SAN JOAQUIN COUNTY L. IROMMENTAL HEALTH DEPAR ENT MASTERFILE RECORD INF•ORNIATION FORNI New EH Program at Existing Fa Facility ID ❑New EH P m Record rD ogram and New Faci Facility Address \-V1100 � L (Please Check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600)— Square Footage Food Handlers Course required: YES ❑ No ❑ 11 Restaurant: Seating Capacity q ❑Vending Machines --Number of Units ❑ Commissary ❑Dry storage only ❑with FoodEl Preparation h Meat Market only [I Multiple Departments ❑ Prepackaged Goods Only ❑ Retail Market ----Square footage Vehicle Type ❑ Mobile Food Vehicle -----Make License # Registration # Vehicle Type [I Mobile Food Prep Unit --Make License Registration # to ❑ Temporary Food Facility -----Dates of operation from ElSpecial Event --Dates of operation from to _ Color Sticker #_ _ Color Sticker #_ ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade B Dairy El blilkDispenser --- Number of Containers in Multi -Head Unit El Grade A Dairy CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) ❑Rec cle / Exempt System (2299) ❑ Hazardous Waste Generator ------------Tons Generated Per Year y y ('2217) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2322) ❑Appliance Rec clers Tiered Permitting Facility ---- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ,_/ ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste LTJ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST \ UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) C%se UST A and B forms HOUSING PROGRAM (2400) ❑ Jailor Exempt Institution ----Number of Units C3 Hotel/Motet -------Number of Units Employee Housing (2700) Use Emplotee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment [IUST-CAPSite El Local HNN' Cleanup Site C1NPL/SEP Cleanup Site F-1 UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) [I out of Service Pool/Spa ❑Natural Bathing Area Number of Pools/Spas at Facility LJ Pool El Spa VECTOR CONTROL PROGRAM (4000) ❑ Kennel ❑ Poultry Farm ------Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Permanent Cosmetics (4122) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) Capacity_.Vehicle # ❑ Pumper Vehicle --Registration # License # ❑Package Treatment Plant ❑Chemical Toilets -------Number of Units ❑ Pumper Yard SOLID WASTE PROGRAM (4400) ❑ Sludge/Ash Site ❑ Transfer Station ❑ Ag /Cannery Waste Site ❑ Landfill ❑ CIA Landfill Site ❑ Process/Recycle Facility ❑ Waste Tire Facility ❑ Compost Facility ElFarm/Ranch Cleanup Site ❑ Refuse Vehicles --Number of Units Dumpsters > 20 cu }'d ---Number of Units MEDICAL WASTE PROGRAM (4500) ❑ Skilled Nursing ❑Large Generator [I Small Generator ❑Limited Hauler 11 Primary Care ❑ Acute Care ❑ [I Common Storage Facility ----- 02-10 ------- 11 - 60 -----❑ > 60 generators ❑ Transfer Station ❑ Veterinary Clinic PUBLIC WATER SYSTEM PROGRAM (4600) Use PfVS EHD 46-02-003 Blue Application Form AGILITY AND/OR PROGRAM CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS F Night Ph Day Ph PROGRANIELEL MENT a" vv FEE I\$PECTOR# PERMIT VALID \ t7y ❑ Check # AMOUNT PAID_ o� u %_asn 48-02-034 10/6/2003 ❑ Surcha ge FEE to \a 3\ 0 Date ACCOUNTING OFFICE L'6 LI Other r EE ❑ Food Handler INVOICE # Date Masterfile Record Pink