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SAN JOAQUIN COUNTY ENVIRONMENTAL I1EALT11 DEPARTMENT MASTERFILE RECORD INFORMATION FORM i ❑New EH Pro at Existing,Facility New EH Program and New Facility Facilit ID Program Record ID Facility Address (Please Check the appropriate description and specify EIM number of units and pertinent information.) FOOD PROGRAM(1640) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course re�c aired:. YES❑ No 13 ❑ Commissary 0 Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units [I Retail Market----Square footage ❑with Meat Market only 11 multiple Departments [3Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ©Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dates ❑ Produce Stand_f operation from to ❑ Ice plant ❑ Special Event —Dates of operation from to DAIRY PROGRAM(2000) E7 Grade A Dairy. ❑Grade B Dalry ❑Milk Dispenser Number of Containers in Multi-Head Unit CUPA ❑State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) 1 E3 Recycle l Exempt System(2299) 13 Hazardous Waste Generator. Tons Generated Per Year ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility-------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit By Rule Famed Unit ❑Permit-By-Rale Household Hazardous Waste F6BOVEGROUND STORAGE TANK FACILITY(ASI)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms HOUSING PROGRAM(2400) ❑Hotel/lAotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2704)Use Employec Hobor Camp AWliaadva Form SITE MITIGATION(2900) - - UNDERGROUND INJECTION CONTROL.(3000) 13 Environmental Assessment 13 UST-CAP Site El Local ITW Cleanup Site. 13NPUSEP Cleanup Site ❑UIC site ❑Abandoned HW`Site ❑ non NPLISEP Cleanup Site ❑RWQCB Cleanup Site -❑Nater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility. ❑P9ol ❑Spa ❑Out of Service PoollSpa ❑Natural Bathing Area VECTOR.COHTROL PROGRAM(4000) ❑Poultry Farm Maximum number of birds ❑Kennel TAnOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) [I Tattooing(412 1) E3 Body Piercing(4120) ©Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑Pumper Vehicle—Registration# License# Capacity Vehicle# 0 Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE.PROGRAM(4400) 13 Landfill 11 Transfer Station 1:1 Ag/Cannery Waste Site ❑Sludge/Ash Site ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA,Landfill Site ❑Refuse Vehicles Number of Units ❑Dutnpsters>20 cu yd--Number of Units ❑FarmManch Cleanup Site MEDICAL WASTE PROGRAM(4500) 13 Primary Care ' ❑Acute Cars ❑ 51311ed Nurs'ufg 13 Large Generator { Small Generator [3 Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-13 2-14 ❑ 11-60----❑>60 generators PUBLIC WATrzk SYSTem PROGRAM(4600)Use PWSELrD 46-02-003 Blue A licarion Form EMERGENCY NOTIFICATION FORTHIS FACILITY ANDIPR PROGRAM CONT'AC'T PERSON Day Ph Night Ph PROGRAMELE.MENT g© FEE ❑ SurchargeFFE •. ❑ Other FEE INSPECTOR# PERMrrVALID to ❑ Food Handler ❑Check# AmOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCouNTING OFFICE Date 1--1171,9