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SAN JOAQUIN COUNTY EN cONMENTAL HEALTH DEPAW. y NT MASTERFILE RECORD LNFORMATION FORM ❑ New EH Program at Existing Facility 1twew EH Proom and New Facility Facility ID Proaram Record II) Sa� Facility ?Address Z 9 L/) i (Please Check the appropriate description and specify sig, 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 ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑ 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 (2217) 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) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use LISTA and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel -------Number of Units ❑ Jail or Exempt Institution -----Number of Units Employee Housing (2700) Use Employee Housin,Y/Lahor 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 Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ 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 N ehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4600) ❑ Priman Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2 - 10 ---- ❑ 11 - 60 ------13 > 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 � K'�O FEE � ' ❑ Surcharge FEE ❑ Other FEE INSPECTOR = ✓ PERMITVALID to El Food, Handler ❑ Check = ANIOUNT PAID Date INVOICE # ❑ Cash REVIEW ED BY ACCOUNTING OFFICE LL21Date 48-02-0.4 Masterfile Record Pink 10/6 2003