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SAN JOAQUIN COUNTY EN` NMENTAL HEALTH DEPARTI X <br />MASTERFILE RECORD INFORMATION FORM <br />"EkNew EH Pro ram at Existing Facility ❑New EH Pro ram and New Facility <br />Facility ID Program Record ID/��i i. 5' J `�71771 <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />C3 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES C3 No 13 <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines --Number of Units <br />❑ Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -----Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit -Make Vehicle Type Color <br />Registration # License # Sticker # <br />11 Temporary Food Facility ----- Dates of operation from to ❑Ice Plant <br />❑ Special Event -- Dates of operation from to 13 Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser --Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------Tons Generated Per Year ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ------------------❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />tJNDI?RGROUND STORAGE "TANK (IJS'I') PROGItAM (2300) (/eve l/STA and B Loans <br />HOUSING PROGRAM (2400) <br />❑ hotel/Motel-------Number of Units ❑ Jail or Exempt Institution -------Number of Units <br />Employee housing (2700) Use Employee Housinp/Labor Cnn1!p Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAI' Site ❑ Local I 1 Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool 13 Spa ❑ Out of Service Pool/Spa El Natural Bathing Arca <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds El Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />13 Tattooing (412 1) ❑ Body Piercing (4120) ❑Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # Capacity Vchicic 11 <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ------Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑Sludge/Ash Site <br />I,T(Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd ----Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care El Acute Care El Skilled Nursing ❑ Large Generator 11 Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ---- ❑ 2 - 10 ------- ❑ 1 1 - 60 ------ ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT 4740 FEE _ <br />INSPECTOR # C'C(r., G' PERMIT VALID <br />❑ Check 4 AMOUNT PAID <br />❑ Cash REVIEWED BY -T,; <br />48-02-034 <br />1(1/(10 f 101 <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE 4 <br />Date <br />Masterfile Record Pink <br />