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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPARdN T MASTERFILE RECORD INFORMATION FORM . New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID {� D O Program Record Facility Address (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course required: l rs 11 No El ❑ 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 --Datesofoperation from to ❑ Produce Stand DAIRY PROGRAM (2000) 11Grade A Dairy C1Grade B Dairy ElMilk 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------------------El 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 Housinky/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 Pools/Spas at Facility 11 Pool El Spa ❑ Out of Service Pool/Spa 11 Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm -------Maximum number of birds C3 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4 120) ❑ 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 1:1 Transfer Station El 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 El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----E3 2- 10------- ❑ 11 -60------❑ ?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 ��y© FEE ❑ Surcharge FEE ❑ Other FEE INSPF,CTOR# 2a'&'J PERMIT VALID to ❑ Food Handler INVOICE# ❑ Check# AMOUNT PAID Date i ❑ Cash REVIEWED BY /L''s 1? � OG ACCOUNTING OFFICE _- Date L 2-l O LI Masterfile Record Pink 48-02-034 10/6/2003