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l SAKI JOAQUIN COUNTY EN ONMENTAL HEALTH DEPAR'1;�'�NT q� MASTERFILE t RD INFORMATION FORM SOI New EH Pro ram at Existing Facility ❑New EH Pro ram and New Facilit Facilit ID Pro ram Record Ill Facility Address ZZ _7 (Please Check the appropriate description and specify size,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 it License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicic Type Color Registration It License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to ❑ lee Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRYPROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-I lead 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 IIouschold Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B(arms HOUSING PROGRAM(2400) ❑ Ilotel/Motel-------Number of Units ❑ .Jail or Exempt Institution-------Number of Units Employee(lousing(2700) Use Emplopee 11ousinglLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ 11S'1'-CAI'Site ❑ Local 11W Cleanup site ElNI'L,/51:1'Cleanup Site El 111C site ❑ Abandoned IIW 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 it 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 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 E11D 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACTPERSON `�ii Day Ph Night Ph PROGRAM ELEMENT �� T� FEE El Surcharge FEE 13 Other FEE INSPECTOR# 3(p PERMIT VAL.11) to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWF.D nY AccoUNTING OFFICE. Date ,Z .5 �S 48-02-034 Masterfile Record Pink 11/18/03