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SAN JOAQUIN COUNTY EVRONMENTAL HEALTH DEPAR ANT <br />MASTERFILE RECORD INFORMATION FORM <br />__X New EH Program at Existing Facility ❑New EH Program and New Facilitv <br />Facility ID Program Record ID Z J1 <br />Facility Address f to 2L-1 AF M\_1 <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />Square Footage <br />❑ Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑ Retail Market ----Square footage <br />❑ with Meat Market only <br />❑ Mobile Food Vehicle -----Make <br />Vehicle Type _ <br />Registration # <br />License # <br />❑ Mobile Food Prep Unit --Make <br />_ <br />Vehicle Type <br />Registration # <br />License # <br />_ <br />❑ Temporary Food Facility -----Dates of operation from <br />❑ Special Event --Dates of operation <br />from to <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines --Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt 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 -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (4399) 1>UUa4eF of-AgT Z93 1 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A 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 Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC 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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm --------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4 100) <br />❑ Kennel <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration #,, License # Capacity Vehicle # <br />❑ Pamper Yard ❑ Package Treatment Plant ❑ Chemical Toilets -------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Sludge/Ash Site <br />❑ CIA Landfill Site <br />❑ Farm/Ranch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- ❑ 2 - 10 ------- ❑ 11 - 60 ------ 1:1 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # 7% I [ ' <br />❑ Check # <br />❑ Cash <br />48-02-034 <br />10/6/2003 <br />1 FEE _ <br />PERMIT VALID <br />AMOUNT PAID <br />Day Ph �jn — `1 1 [ I— N 7 Night Ph <br />❑ Surcharge FEE <br />to <br />Date <br />REVIEWED BY n,, 'r✓ ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />Date <br />Masterfile Record Pink <br />