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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facilitm ID Program Record ID Facility Address -) 7 b (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: YES l 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 UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2700) Use Employee Housinq& bor Camp 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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ 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 ❑ � h Site ❑ Waste Tire Facility El Facility ❑ Process/Recycle Facility 11 - 11 Refuse Vehicles(#of units) ElDumpsters>20 cu yd(#of units) 11 Fa nup Site MEDICAL WASTE PROGRAM(4500) �/�V 11 Primary Care El Acute Care El Skilled Nursing 11 Large Generator 11 Small Generattid j girmiled Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 041vS8 ❑ > nerators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form H ENV�R QU/N C �t EMERGEN Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM EALT/y OF qR TAL T y, CONTACT PERSON 1 Day Ph - fight Ph TMENr PROGRAM ELEMENT FEE l ❑ Surcharge FEE ❑ Other FEE INS ECTOR# PERMIT VALID t0 ❑ Food Handler Rf Check# AMOUNT PAID Date S 20 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07 Pio�t58'3�