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SAN JOAQUIN COUNTY ' 'VIRONMENTAL HEALTH DEPAP' 1ENT <br /> MAS�ERFILL RECORD INFORMATION FORM <br /> New EH Program at Existing Facility []New EH Program and New Facility <br /> Facilit ID � Program Record ID P�053 5 \y <br /> Facility AddressIdei <br /> 1') � j <br /> (Please check the approption and specify size, number of units and pertinen information.) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Square Footage Food Handlers Course required: YES ❑ No ❑❑ Commissary ❑ Dry ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Squa ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility--Dz tes of operation from to ❑ Ice Plant <br /> ❑ Special Event Dates of opera ion from to ❑ Produce Stand <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA State Facility Surcha ge(2399) <br /> HAZ US WASTE PROG AM(2200) .L. <br /> Hazardous Waste Ge erator----------- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers( 218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facilit ------------------- ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STO AGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STO AGE TANK(UST)PROGRAM (2300) Use UST A and B forms <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Uni s ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Em o ee Housin /Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (400 ) <br /> ❑ Poultry Farm-------Maximum nu ber of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMAN NT COSMETIC PROGRAM (4100) <br /> ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ tCarO <br /> tion ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility Compcility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles P of units) ❑ Dumpsters>20 cu yd (PI or Units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4 <br /> ❑ Primary Care ❑ AcutSkilled Nursing O Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Vete ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGse PWS EHD 46-02-003 Blue Application Form <br /> ENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PER IT VALID G �t. to PPI El Food Handler <br /> ❑ Check# AMOUN PAID Date INVOICE# 61, Lk9 <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date l d <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />