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SAN JrOAQUIN COUNTY ENVZRONM.ENTAL REALM DEPARTAENT MASTERFILE RECORD INFORMATION FORM ❑New Ell Program at Existing Facility ❑New EH Program and New Facility CFacilit y ID l Program Record ID Facility Address , '(Please Check the appropriate description and specify sire,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 Machices—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 Uait—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility—Dates of operation frost to 13 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) ❑ 11azardous Waste Generator----- Tons Generited Per Year ❑ Recycle 1 Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Reeyders(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ! ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste k ❑ ABOVEGROUND STORAGE TANK FACILITY(AST),(2390) Number o£AST I UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USIA and.9 Lorms I HOUSING PROGRAM(2400) ❑Hotel/Motel Number of Units .❑.Tail or Exempt Institution Number of Units Employee Housing(2700)Use Employee Aousirt /Labor Camp Application Form SITE MITIGATION(2990) UNDERGROUND INJECTION CONTROL(3000) 11Enronmental Assessment [IUST-CAP Site ❑Local MV Cleanup Site. ❑ NPLISEP Cleanup Site 11 UIC Site vi ❑ Abandoned IfW Site ❑ non-NPL(SEP Cleanup Site ❑R\3VQCB 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 Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) [ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4290) ' /// Yumper Vehicle—Registration# �_ �ll�!!A License# i[/l __ Capacity lL�kt� 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 ❑ Dumpsiers>20 cu yd----Number of Units ❑Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑ Limited Hauier ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—_0 2-10 ❑ 11-60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PN,SERD46-02-003 BlacApplkafior:Form Mr-RGFNCY N RT IFI CATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Q fight Ph PROGRAM ELEMENT FEE ❑ Surcharge FFE ❑ Other FEE INSPECTOR# 9 PERMIT VALID to ❑ Food handier ❑ Check x AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE- Date Masterfile Record Pink