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SAN JOAQUIN COUNTY EN :ONM'ENTAL HEALTH DEPARTi �T MASTERFILE RECORDINFORMATIONFORM ❑New Eli Program at Existing Facility ❑New EH Program and New Facility Facilif ID Program Record ID Facility Address ST't (Please heck the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ 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(20W) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) IL47,ARDOUS WASTE PROGRAM(2200) 9 ❑ hazardous Waste Generator----------Tons Generated Per Year ❑Recycle t Exempt Systent(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Per"tting 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 USIA and B forms HOUSING PROGRAM(2400) ❑ IIotel/Motel--Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Emploree Ifousine/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) 9 Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPLISEP Cleanup Site 11UIC Site ❑ Abandoned IIW Site ❑non-NPLlSEP Cleanup Site ❑RWQCB 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) ❑ Poultry Farrar Maximum number of birds ❑ Kennel TATTOO BODY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ 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 ❑ 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 ❑ Limited Ilauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2-10--❑ 11-60-----❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use P►i'S E11D 46-02-003 Blue Application Foran EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACI'PERSON t+� Day Ph Night Ph PROGRAM ELEMENT `t`�y FEE 7 ❑ Surcharge FEE ❑ Other FEE INSPECTOR# C{c( PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID 7 Date 3-7-1 2 INVOICE# ❑ Cash REVIE=WED BY ACCOUNTING OFFICE Date Masterfile Record Pink