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SAN JOAQUIN COUNTY Ei �RONMENTAL HEALTH DEPAR ENT MASTERFILE RECORD INFORMATION FORM New EH Pro am at ility ❑New EH Program and MFlaciliFacilit ID � Pro ram Record IDFacilityAddress V— D (Please Check the appropriate description and specify size,number of units and aertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Ws❑ No ❑ ❑ Commissary ❑ Dry storage oly El with Food Preparation ❑Vending Machines—Number of Units 11 Retail Market----Square footage ❑ with Meat Market only 11 Multiple Departments El Prepackaged Goods Only El Mobile Food Vehicle-----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility-----Dales of operation from to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ 3rade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharg (2399) HA_ZARDOUS WASTE PROG IAM(2200) X4aazardous Waste Ge rator------------Tons Generated Per Year 'C El Recycle/Exempt System(2299) ❑ CRT Offsite Handler (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 STORA E TANK(UST)PROGRAM(2300) Use UST A anti B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution------Number of Units Employee Housing(2700)Use Employ HousingalLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment E UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site E non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROG M(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4 00) ❑ 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 El Package Treatment Plant ❑ Chemical Toilets-------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Trans er Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Comp st 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(450 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----112- 10-------❑ 11 -60------❑ >60 generators PUBLIC WATER SYSTEM PROG M(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY N TIFICATION F9R THIS FACILITY AND/OR PROGRAM CONTACT PERSON ` Day Ph a? Night Ph PROGRAM ELEMENT FEE V U ❑ Surchar a FEE ❑ Other FEE INSPECTOR# PE IT VALID ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BYACCOUNTING OFFICE Date f l3 48-02-034 V I ?/!/� i Mast dile Record Pink 10/6/2003