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SAN JOAQUIN COUNTY EN NMENTAL HEALTH DEPART NT MASTERFILE RECORD INFORMATION FORM Ne%v EH Program at Existing Facility ❑New EH Program and New Facility Facility ID FA 0C1 3 Program Record ID 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: 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) 1:1 Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of:QST UNDERGROUND STORAGE TANK(UST) PROGRAM (2300) Use USTA and B(arms HOUSING PROGRAM(2400) ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units Employee(lousing(2700) Use Employee Housing/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 fools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) 11Poultry Farm -------Maximum number ofbirds E:1 Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4 100) ❑ Tattooing(4 12 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) a ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site V1 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Reruse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Fann/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El Small Generator 1:1 Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 02- 10- 10------- ❑ 1 l -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 L(_7y L' FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PtiRMIT VALID to ❑ Food Handler ❑ Check# AM1IOOUNT PAID Date INVOICE# ❑ Cash REVIEWED B1' {� 110 ACCOUNTING OFFICE Date ( O Masterfile Record Pink 48-02-04 10/6.2003