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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM .New EH Program at Existing Facility w EH Program and New Facility Facitifi ID .> Program Record ID Facility Address pSte, � (Please oheck the appropriate description and specify size,number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: ,YEs❑ No❑ CI Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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) 11 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 LISTA and B farms HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use Emptovee Housing/Labor Camp Appfica#ion Farm SITE MITIGATION(2900) UNDERGROUND INJECTION CONTRO (3000) ❑ Environmental Assessment 1] UST-CAP Site ❑ Local HW Cleanup Site 13NPLISEP Cleanup Site D UiC Site ❑ Abandoned HW Site ❑ non-NPLtSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa [3Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennet TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) Tattooing;(4121) 171 Body Piercing(4120) ❑ Permanent Cosmetics(4122) "-QUiDV'.ASTE PROGRAM 0200) Pumper VehicleRegistration# License# Capacity 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 ElProcess/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ FarmlRanch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station 0 Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 glue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON S' V - t n°t S (, Day Ph Zit Z -2) (o Night Ph PROGRAM ELEMENT 44%jo FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR PERMIT VALID to ❑ Food Handier ❑ Check# AMOUNT PAID _ Date I INVOICE Cash REVIEWED BY ACCOUNTING OFFICE '; Date MASTERFILE RECOR 48-02-034 ,:... k