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I: SAN JOAQUIN COUNTY F'?'VIRONMENTAL HEALTH DEPARENT t MASTERFILCORD INFORMATION FORM ❑ New EH Program at E rxisting Facility ❑New EH Program and New Facility FacilityID b Q Program Record ID a� Facility Address II Z � (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) li ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged 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 f=acility--Dates of operation from to ❑ Ice Plant ❑ Special Event Dates of'operation from to ❑ Produce Stand DAIRY PROGRAM (2000) !' ❑ Grade A Dairy it ❑ 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 Han idlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility-------------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- ule Household Hazardous Waste ,'ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USIA andEl forms ROUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ---Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ 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 I ❑ 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(#or Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site li 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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON p, Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# j'L 0� PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED 1.BY ACCOUNTING OFFICE Al Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07