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SAN JOAQUIN COUNTY@VIRONMENTAL HEALTH DEPAF ENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facilitv ❑New EH Proqram and New Facilitv Facility ID Program Record ID /' Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type_ Registration # License # ❑ Mobile Food Prep Unit Registration # ❑ Temporary Food Facility --Dates of operation from ❑ Special Event Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) Make License # to Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments❑ Prepackaged Goods Only Color Sticker # Vehicle Type Color Sticker # 2.9 _ ❑ Ice Plant ❑ Produce Stand ❑ Milk Dispenser -Number of Containers in Multi -Head Unit ❑ 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) ❑ ConditionalllEExempt (CE) ElPermit-By-RuleFixed Unit ❑ Permit-By>Ru 'Household Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution - -- mber 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # ❑ Pumper Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ 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 1:12 - 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/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT C� ? FEE ❑Surcharge FEE 11 Other FEE INSPECTOR-,"' PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE I Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07