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SAN JOAQUIN COUNTY EN v 1RON1MENTAL HEALTH DEPARTi <br /> r MASTERFILE RECORD 1NFOR`NIATION FORM <br /> []New EH Program and New Facility <br /> New EH Pm'--ram at ExistingFacility 3 <br /> Facility ID Q Program Record ID <br /> Facility Address <br /> Lf S- <br /> (Please Check the appropriate description and specify size,number units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required:—YES❑ No ❑ <br /> ❑Restaurant: Seating Capacity Square Footage <br /> ❑ Commissary ❑ Dry storage only <br /> ❑ with Food Preparation ❑Vending 1lachines—Number of Units <br /> ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> 11o <br /> Retail Market----Square footage Vehicle Type <br /> ❑ Mobile Food Vehicle-----Make License# Sticker# <br /> Registration# Vehicle Type Color <br /> ❑ N obile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ <br /> Temporary Food Facility-----Dates of operation from to 11Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> [1 Grade El Milk B Dairy Dispenser---Number of Containers in Multi <br /> ❑ Grade A Dairy -Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(7200) ❑ Recycle/Exempt System(2299) <br /> Tons Generated Per Year 2217 <br /> �Iiazardous Waste Generator------------ »» El Appliance Recyclers ( ) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Conditionally Exempt(CE) <br /> Tiered PermittingFacility --- [I Conditionally Authorized(CA) Rule Household Hazardous Waste <br /> y— ❑ Permit-By-Rule Fired Unit ❑ Permit-By- <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use LISTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution----Number of-Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use Employee flousin!Z/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) UIC Site <br /> te❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HN�CR"QCB Cleanupp Site ❑Sit NPL/SEP <br /> Cleanup Si <br /> Water Quality Remediation Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) ElNatural Bathing Area <br /> Cl Pool [I Spa C] out of Service Pool/Spa <br /> Number of Pools/Spas at Facility <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm-----Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) [I Permanent Cosmetics(4122) <br /> El Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> License# <br /> ❑ Pumper Vehicle--Registration# ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/ Ash Site <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ CIA Landfill Site <br /> ❑ Landfill ❑ Process/Recycle Facility' El Farm/Ranch Cleanup Site <br /> ❑ Waste Tire Facility ❑ Compost Facility C1 Dumpsters>20 cu yd----Number of Units <br /> ❑ Refuse Vehicles--Number of Units . C1 <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ skilled Nursing ❑ Large Generator ❑ 1 1 -60------❑ >60 generators <br /> El Primary Care ❑ Acute Care ❑ Common Storage Facility-----02- 10------- <br /> ❑ Transfer Station C3 Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIyS EHD 46-02 003 Blue Application <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR OR PROGRAM <br /> Night Ph <br /> CONTACT PERSON M VA <br /> N <br /> ❑ Surcharg FEE ❑ Other FEE <br /> FPROGRAMENT 7 Z Z Q FEE LO a ❑ Food Handler <br /> 3► PER�4[T VALID I 0jrryOlCE# <br /> AViOU`iTPAID Date Date <br /> REVIEWED BY ACCOtMING OFFICE <br /> Masterfi a Record Pink <br /> 48-02-034 <br />