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SAN JOAQUIN COUNTY i-,I VIRONMENTAL HEALTH DIVISwN MASTERFILE RECORD INFORMATION FORM EH 00 09 ❑New EH Program at Existing Facility ❑New EH Program and New Facility Facilit IDS Fro ram r b l� ! 7 'Record ID .. Lf Facility Address2, (Please Check the appropriate description and specify sire,number of units and pertinent information) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity } Square Footage Food Handlers CourseLquired: YEs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation Oven,ding 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 Dispenscr---Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) PAYMENT IIAZARDOUS WASTE PROGRAM(2200) RECEIVED ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(MR 2 " Ul ❑ Permit-By-Rule Fixed Unit 13 Permit-By-Rule House 9pld Hazardous Waste ❑ ABOVEAN JOAQUIN COUNTYGROUND STORAGE TAMC FACILITY(AST)(2390)----Number of AST PUBLIC HEALTH SERVICES UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and R forms ENVIRONMENTAL HEALTH DIVISION HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution Number of Units Employee liausing(2700) Use Employee Hoersin lLabor Caurn Application Form . SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP CIeanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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 Farm--------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIC,IUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant hemical Toilets-------Number of Units _Z0 SOLID WASTE PROGRAM(4400) ❑ Landfill © Transfer.Station 11Ag/Cannery Wasle Site 13Sludge/Ash Site ❑ Waste Tire Facility 11Compost Facility ❑ Process/Recycic 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 Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10-------❑ 11 -60------El >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS E.f1006?_Blue Anplication Form EME OTIFICATi N FOR THIS FACILITY ANEVOR PROGRAM CONTACT PERSON 1✓ Day Ph ZO, __7VS--?Z-7- Night Ph 2!y:Z- ass , PROGRAM ELEMENT Z FEE,' gb" �' ❑ $urCharge FEE ❑ Other FEE ff — INSPECTOR# b PERtMIT VALID: � U-41"d r3��. to ��y, ��/�� Q ❑ Food Handler 0 C eck N AMOUNT PAID.: ( Date INVOICE# O0 gals 2 71 Cash REVIEWCD nY 1k V\ .: AccouNnNG OFFICE Date 0-4/05/0