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SAN JOAQUIN COUNTY'-"VIRONMENTAL HEALTH DEPAFIENT <br /> MASTERFILECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facili ❑New EH Program and New Facility <br /> Facility ID Z 2 Z W & Program Record ID <br /> Facility Address L 0 9 3 <br /> (Please check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM (1600) <br /> C3 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation [Wending Machines Number of Units <br /> ❑ Retail Market---Square footage ❑ with Meat Market only ❑ Multiple Departments[] Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle–Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator-----------Tons Generated Per Year ❑ Recycleitxempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-lay-Rule Fixed Unit ❑ Permit-By- ousehold Hazardous Waste <br /> YABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USIA and B forms <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing(2700)Use Fm to ee Housing/Labor Camp Annfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> E l Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site [3NPUSEP Cleanup Site ❑ U!C Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry f=arm------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care 1:1 Acute Care ❑ Skilled Nursing 1:1 Large Generator ❑ Small Generator 1:1 Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12-10 011 -60 ❑ 5 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Blue Aplolication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 2 81 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR M6- -/—! PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date Az <br /> 48-02-634 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />