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SAN JOAQUIN COUNTY HEALTH DEPAF ]ENT MASTERFIL:E RECORD INFORMATION FORM ❑ New EH Pro ram at Exi>stin Facility []New EH Pro ram and New Facilit Facilit ID 3 / Pro ram Record ID Facility Address ? 7— (Please check the appropriate description and specify size,number of units and pe inent information.) FOOD PROGRAM (1600) (3 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES No ❑ ❑ ❑ Commissary ❑ Dry storage only 13with Food Preparation [Wending 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 Coior Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to 11 lee 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) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-0-- ber ousehold Hazardous Waste XABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numberof AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use LISTA and B formsHOUSING PROGRAM(2400) [3Hotel/Motel---Number of Units ❑ Jail or Exempt Institution of Units Employee Housing(2700) Use Employee Housin /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-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) ❑ 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 VehicleRegistration# 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>20 cu yd(#or 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 1:12- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Application Farm EMERGENCY NOTIFICATION FOR THIS FACILITY ANWOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENTZ FEE El Surcharge FEE 13 Other FEE INSPECTOR , gPERMIT VALID t0 ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date r 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07