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x SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPAK ENT MASTERFILE RECORD INFORMATION FORM 1 it �I ❑ New EH Program at Existin Facilit El New EH Pro ram and New Facility Facility ID Pro ram Record ID a Facility Address ,I (Please check the appropriate description and specify size,number of units and eminent information.) FOOD PROGRAM (1500) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No 13 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending Machines Number of Units I ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Calor i� Registration# License# Sticker# ❑ Mobile Food Prep Unit Make Vehicle Type Color Registration# License# Sticker# ; ❑ Temporary Food Facility--Dates of operation from to ❑ 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 II CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator----------- Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(221 S) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) I Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- a ousehold HazardousWaste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST / _UNDERGROUND STORAGE TANK(UST)PROGRAM (2300) Use USIA and B forms .L.r HOUSING PROGRAM(2400) II ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units !I Employee Housing(2700)Use Employee HousincIlLabor Camp AiRiglication Form I SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) II ❑ 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) iI ❑ Poultry Farm-----Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC,PROGRAM (4100) i ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) !I LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# I� ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units q 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 V of Units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) d ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003„Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph li PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE I� INSPECTOR#C.f D / P,9 PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 'I 48-02-034i MASTERFILE RECORD INFORMATION PINK 11115!07 II .. it