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SAN JOAQUIN COUNTY ' 'VIRONMENTAL HEALTH DEPAR- 'ENT MASTERFILE'RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID / ,7 '2- 7 Program Record ID 3 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 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 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 UST Aand B forms 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 ❑ Kennel TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# 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(#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/Oft PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 2- FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR ' PERMITVALID to El Food Handler ❑ Check# / AMOUNT PAID Date INVOICE# [3 Cash REVIEWEDBY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07