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SAN JOAQUIN COUNTY LE`'` IRONMENTAL HEAL RMDEPA --NT y MASTERFIRECORD INFORMATION FO ❑New EH Pro rain and New Facilit ❑ New EH Pro ram at Existin Facilit a� Facilit ID Program Record ID Facility Address 0 Al°z90'd (Please check the appropriate description and specify size, number of units and erttw information.) FOOD PROGRAM(1600) El ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course reguired_ 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 License# Sticker# Registration# Vehicle Type Color 13 Mobile Food Prep Unit Make Registration# License# Sticker# to ❑ Ice Plant ❑ Temporary Food Facility--Dates of operation from ❑ Produce Stand ❑ Special Event Dates of operation from to 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) ❑ Conditiona mpt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-13,(n ermit-B Rule usehold Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B forms I HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution---- umber of Units Employee Housing(2700) Use Employee Housin /Labor CamD ADjolication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ LIST-CAR Site [J Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQC13 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) El Poultry Farm-------Maximum number of birds Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) 13 Tattooing(4121) ❑ Body Piercing(4120) Permanent Cosmetics(4122} LIQUID WASTE PROGRAM (4200) ❑ Pumper Veh icle Regi stration# 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- 10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHO 46-02-003 Blue Appllc_ation Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT *Zg FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to I-] Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date t 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07 S