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SAN JOAQUIN COUNTY EN" "I"ONMENTAL HEALTH DEPARV4,P.NT MASTERFILE K. f1D INFORMATION FORM ew EH Program at Existing Facility ❑New EH Program and New A acilit Facili ID F/4 L OL)("2 L' 75'- Pro ram Record ID Facility Address 3( L (Please Check the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) Food Handlers Course required: YES No El 11 Seating Capacity Square Footage ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units 11 Retail Market----Square footage El with Meat Market only [3 Multiple Departments ❑ Prepackaged Goods Only 11 Mobile Type Color Mobile Food Vehicle-----Make Sticker# Registration# License# ❑ Mobile Food Prep Unit-Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dates of operation from to 11 Ice Plant ❑ Special Event --Dates of operation from to 11 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 UST A and B forms HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution--Number of Units 1:1 Hotel/Motel-------Number of Units Employee Housing(2700)Use Employee Housing/Labor.Cama 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) ❑ Spa [I out of Service Pool/Spa ❑ Natural Bathing Area Number of Pools/Spas at Facility 11 Pool VECTOR CONTROL PROGRAM(4000) ❑ Kennel ❑ Poultry Farm Maximum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) [3 Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# [3 Pumper Vehicle-Registration# ❑ Package Treatment Plant 11 Chemical Toilets------Number of Units ❑ Pumper Yard g SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site 1:3 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site g ❑ Process/Recycle cle Facility ❑ CIA Landfill Site Waste Tire Facility ❑ Compost Facility y ❑ Farm/Ranch Cleanup Site [3 Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units MEDICAL WASTE PROGRAM(4500) ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Primary Care 11 Acute Care ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10------- 1:111-60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EVD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT `f 7k U FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# CCL-C, PERMIT VALID to ❑ Food Handler ❑Check# AMOUNT PAID Date /J INVOICE# 13 Cash REVIEWED BY � f ACCOUNTING OFFICE L" Date ) Masterfile Record Pink 48-02-034 10/62003