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SAN JOAQUIN COUNTY El 1RONMENTAL HEALTH DEPAR_ SENT <br />' MASTERFILE RECORD INFORMATION FORM <br />m New EH Prouam at Existing Facilitv ❑New EH Proeram and New Facilitv <br />Facility ID t 6 " -> <br />Facility Address 3-3 U <br />(Please Check the appropriate descriptic <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity <br />❑ Commissary ❑ Dry storage only <br />❑ Retail Market ----Square footage_ <br />❑ Mobile Food Vehicle -----Make _ <br />Registration # _ <br />❑ Mobile Food Prep Unit --Make _ <br />Registration # <br />❑ Temporary Food Facility ----Dates of operation from <br />❑ Special Event --Dates of operation from <br />Program Record IDV' <br />0r- S vG/c-To Al <br />and specify size, number of units and pertinent information.) <br />WA <br />Square Footage Food Handlers Course required: YES ❑ No ❑ <br />❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />Vehicle Type <br />License # . <br />Vehicle Type <br />License # <br />to <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <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) (2390) Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and s <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee HousinQ/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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -----Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle --Registration # I License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ----- 02-10 ------- ❑ 11 - 60 ------ 13 > 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 Day Ph Night Ph <br />PROGRAM ELEMENT 2 S 3 FEE ❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR #C,/3 9//S(O ' PERMIT VALID to ❑ Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />48-02-034 Mastertile Record Pink <br />10/6/2003 <br />