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SAN JOAQUIN C.,'OUM Y 1I" -VIR11NNIII-IN IAL 11LAL11-1 LIL1'AI YILN l' iVIASTERFILL r(ECORD INFORMATION FORM New EH Pro ram at Existing Facility ❑New EH Pro ram and New Facilit ; Facility ID Program Record IDS Facility Address ' (Please Check the appropriate description and specify size, number of units and pertinent informa(ion.) 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 Dalry ❑ 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 14J 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 ----Number of Units Employee dousing (2700) Use Employee Housin,e/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 PooWSpas at Facility ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑ Spa ❑ Out of Service PooVSpa ❑ Natural Bathing Area TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100; ❑ Tattooing (412 1) ❑ Body Piercing (4120) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle --Registration # License # ❑ Pumper Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Kennel ❑ Permanent Cosmetics (4122) Capacity Vehicle # 11Chemical 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 --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 ------- ❑ 1 1 - 60 ------ El > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PIVS EHD 46-01-003 Blne Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRANt'ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48=02.034 Masterfile Record Pink 1 (/18/03