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SAN JOAQUIN COUNTY ENWONMENTAL HEALTH DEPARTANT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facilitv Facility ID F� '�)1�y�q Pro ram Record ID P-050-(, 11 Facility Address I I Mo Frit )�� 2 p (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: YE S ❑ 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) ❑ 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(ornts HOUSING PROGRAM(2400) ❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee housing(2700) Use Employee flousing/Lahor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local [INN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RN1'QCB Cleanup Site ❑ Nater 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) C1 Poultry Farm -------Mn.CImUm number of birds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) El Body Piercing(4120) ❑ Permanent Cosmetics(4 122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle-Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units SOLID WASTE PROGRAM(4400) El Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site l_Wastc Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Itefuse Vehicles--Number of Units _ ❑ lhnnpslerS>20 cu yd----NUnlber of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) 1:1 Primary Care El Acute Care El Skilled Nursing ❑ Large Generator E:1 Small Generator El Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10------- ❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PIVS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON11 I� Day Ph Night Ph PROGRAM ELEMENT -T-1 4D FEE ❑ Surcharge FEE ❑ Other FEE I.NSI,I:C-rol;# O0co C PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED dl' 3 i� ACCOUNTING OFFICE Date ( 11b Masterfile Record Pink 48-02-034 10/6/2003 _ i