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SAN JOAQUIN COUNTY EN ONMENT' ' MASTERFIL�.�.�.,ALTH DEPART�NT ❑New EH Pro am at Existin Facili MATION FORM Facill ID - w BH Pro am and New Facili Facili pro ram Record ID s, ty Address �J .. ,� (Please Check the appropriate description and specify size,number o1L POOD PROGRAM(1600) units and eminent information.) ❑Restaurant; Seating Capacity � Square Footage ❑Commissa ry ❑Dry storage only ❑ with Food Pre Food Handlers Course re aired: YEs[] ❑Retail Market----Square footage Preparation —�-� No ❑ ❑Veuding Machines_Number of Units ❑Mobile Food Vehicle-----Make With Meat Market only El Multiple Departments ❑Prepackaged Goods Only Registration# Vehicle Type ❑Mobile Food Prep Unit--Make License# Color Vehicle Type Sticker# Registration# Color ❑ Temporary Food Facili License# operation from Sticker# Facility of ❑ Special Event --Dates of operation from to El lee Plant DAIRY PROGRAM(2000) to ❑ Produce Stand ❑ 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 Housing&Abor Camp Application Farm 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) Number of Poois/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds 11 Kennel TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ 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 ??M SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station 13 Ag.1 Cannery Waste Site © SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle 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 Cl Small Generator ❑ Limited Hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10-------[111 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form Emr=RGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON t I641— Day Ph 6 Night Pb PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEF- INSPECTOR EEINSPECTOR# PERMIT VALID t r f / for t r; - ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ' Masterfile Record Pink 48-02-034 10/6/2003