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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPAR NT ly— MASTERFILE RECORD INFORMATION FORM U1 New EH Program at Existing Facility ❑Neva•EH Program and New Facility y� Facility ID rA 1q Program Record ID �O�a b t'1 ( `� ✓ n Facility Address f g 195 qz,FFa-f 1"� nit and pertinent information. Please Check theappropriate description and specify size,number of units p ) ( FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: les ❑ 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# El Temporary Food Facility-----Dates of operation from to El lee 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 Offs¢te 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(orals HOUSING PROGRAM(2400) ❑ hotel/Motel-------Number of Units ❑ Jailor Exempt Institution-----Number of Units Employee llousing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local FINN'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RNN'QCB 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) El Poultry Farm -------Maximum number ofbirds El Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) El Tattooing(4 12 1) 1:1 Body Piercing(4120) [1 Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) El Pumper Vehicle -Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill El Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site O_Nvaste"hire hacility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Itefuse Vehicles--NllnlbCI'of tJnits _ _ _ ❑ Dumpsters>20 cu yd----Number of Units____ ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) El Primary Care 1:1 Acute Care El Skilled Nursing ❑ Large Generator El 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 P4VS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON / I Day Ph Night Ph [E] ROGRAM ELFINIENT 4-I40 FEE El Surcharge FEE ❑ Other FEE SPI•:C'rot;# OO Q PERMI'fVALID to El Food Handler Check# AMOUNT PAID Date INVOICE# Cash REVIENVED BY ACcoUNTING OFFICE Date ( t1b Masterfile Record Pink 48-02-034 10/6/2003