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SAN JOAQUIN COUNTY L. RONMENTAL HEALTH DEPA, ENT MASTERFILE RECORD INFORMATION FORM F New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID o U 0 - I '� ?, 5,- Program Record ID Facility Address D ( U Z eP (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 ❑ Special Event --Dates of operation from to ❑ Ice Plant ❑ 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 (221 7) 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) umber of AST -2-g 3 / UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -—Number of Units Employee Housing (2700) Use Employee Housing/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 Servide Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4 100) ❑ Kennel ❑ Tattooing (412 1) ❑ 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 --Number of Units ❑ Dumpsters > 20 cu yd ----Number 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 ------- ❑ l 1 - 60 ------ 11 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIPS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGVAM CONTACT PERSON ('j 1 ef%A T S % Z AC,6 u--� Day Ph —U3g I Nig_ttPh PROGRAM ELEMENT FEE �u tW� ❑ Surcharge FEE INSPECTOR # 9 3 t 77 PERMIT VALID to ❑ Check # AMOUNT PAID ❑ Cash REVIEWED BY 48-02-034 10/6/2003 Date ACCOUNTING OFFICE ❑ Other FEE ❑ Food Handler INVOICE ## Date '� . 14. n Recnrd Pink