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SAN JOAQUIN COUNTY EN . _.ONM.ENTAL HEALTH DEPAM _1T EC%jV F_ R . EC��V�D MASTERFILE RECORD INFORMATION FORM Nov 2 S 2011 ❑ New EH Program at Existing Facility ew EH Program andNewFacility SAN JOAQUR4 utas b F1rJIRONK�"L Program Record ID NSTH oEP#TMesT Facility Address (Please Check the appropriate description and specify s, ize, number of units and pertinent information.) FOOD PROGRAM (1600) f ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES ❑ No`Cy—_ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines —Number of Units iZetail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only 14-1;Mobile Food Vehicle --Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit—Make Vehicle Type Registration # License # ❑ Temporary Food Facility --->Dates of operation from to ❑ Special Event —Dates of operation from to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (20W) ❑ Grade A Dairy ❑ Grade B Dairy, ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit COPA ❑ State Facility Surcharge (2399) IIAZARDOUS WASTE PROGRAM (2200) ❑ Hazardous Waste Generator.— Tons Generated Per Year ❑ Recycle I Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Pen -nit -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 UST A and B forms HOUSING PROGRAM (2400) ❑ Hotel/Motel Number of Units 0 Jail or Exempt Institution Number of Units Employee Housing (2700) Use Em pleyee Tlousing-/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local 11W Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC 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 ❑ P401 ❑ Spa ❑ Out of Service PooVSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ 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 ❑ CIALandfrll Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) 13 Primary Care ❑ Acute Care 11 Skilled Nursing 11 Large Generator Q Small Generator 11 Limited Mauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -0 2 -10 ❑ 11 - 60 ------❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use Pll'SGIID 46-02-003 Blue Application Foran EMERGE CY NOTiFtcATjoN FOR THIS FACILITY ANDIOR PROGUAM CONTACT PERSON Day Ph =jRtG —03 h PROGRAM ELER1m\T FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# 2 PERMIT VALIDMM to Z 11 Food Handler sn r� 102-2-2 !2� APIOUNT PAID Z V Date It INVOICE # c/ o11,411- / OC - ❑Cash REVIEWED BY��yC/ ACCOUNTING OFFICE %f/ Date ✓t Macule Record Pink