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SAN JOAQUIN COUNTY r� �RONMENTAL HEALTH DEPAR` VT t MASTI=RFIL� IECORD INFORMATION FORM ❑ New EH Pro ram at Existing Facility ❑New EH Program and New Facilit FacilityID T g Pro ecord ID Facility Address : �/ (Please check the appropriate description and specify size, number of units and_pertinent information.) FOOD PROGRAM(1600) Food Handlers Course required: YES ❑ No ❑ ❑ Restaurant: Seating Capacity Square Footage �� F-1Commissary ❑ 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# El Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# 13 Temporary Food Facility–Dates of operation from to 13 lee Plant ❑ Special Event Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy 0 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) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms 3 HOUSING PROGRAM(2400) El Hotel/Motel----Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700)Use Employee Housin /Labor CampAPplicationForm 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-NPLISEP 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) 1:1 Poultry Farm-------Maximum number of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) 13 Tattooing(4121) ❑ 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) ❑ 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>20 cu yd(#of Units) ❑ Farrn!Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator 13 Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 0 2- 10 011 -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 Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE k INSPECTOR#ill" O gPERMIT VALID to 11 Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 4M2-034 MASTERFILE RECORD INFORMATION PINK 11115!07