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SAN JOAQUIN COUNTY' RONMENTAL HEALTH DEPARWT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existinq Facilitv ❑New EH Proqram and New Facility Facility ID �. �% G/ `.� Program Record ID h'ez"5o2Z {" '7q Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ 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 Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑ Special Event Dates of operation from to DAIRY PROGRAM (2000) Color _ ❑ Ice Plant ❑ Produce Stand ❑ 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) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -B e Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B for s , HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housinq/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 ❑ 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 TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles I# or Units) ❑ Dumpsters > 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 EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night P PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR # r L ERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE ## ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date (C c' 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07