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,SAN JOAQUIN COUNTY f IIRONMENTAL HEALTH DEPARENT MASTERFIILECORD INFORMATION FORM - New EH Program at Existing Facility ❑New EH Program and New Facilit FacilitID (� Pro ram Record ID Facility Address /�N� G14 (Please check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Mending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Calor Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to [j Ice Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers (2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility-------------------❑ Conditionally Authorized(CA) ditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit Pe it-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST) (2390) Number of AS / UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use LISTA an B f ms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCI3 Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool El Spa [3 Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds 13 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters a 20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS FHD 46-02-003 Blue Application Form ' EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON t� Day Ph Night Ph PROGRAM ELEMENT � �S �� FEE 13 Surcharge FEE 1:1 Other FEE INSPECTOR#.C-0 2, PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 49C!�;f 48-02-034 MASTERFILE RECORD INFORMATION PINK 1115107