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Adlh SAN JOAQUIN COUNTY ENV ON 'ENTA.L HEALTH DMAMTM I T MASTERFILE RECORD -INFORMATION FORM ❑ New EH Program at Existing Facility ew EH Program and New Facility Facility ID Program Record ID Facility Address (Please Check the appropriate ddscription and specify slLe,e number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑with Food Preparation 11 Vending Maehines —Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle -----Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit—Make Vehicle Type Registration # License # ❑ Temporary Food' Facility -----Dates of operation from to ❑ Special Event —Dates of operation from to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -He -ad Unit CUPA ❑ State Facility Surcharge (2399) IiAZARDOUS WASTE PROGRAM (2200) i ❑ Hazardous Waste Generator-=-- Tons Generated Per Year ❑ Recycle I 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) ❑ IloteVMotel Number of Units 11 Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee Housix 4abor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL 3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local RW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned IINY Site ❑ non-NPIJSEP Cleanup Site ❑ RNVQCB Cleanup Site . ' ❑ Water QualityRemediation Site' RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility . ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR.CO14TROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) 0 Tattooing (4121) 13Body Piercing (4120) 13Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) 0 Pumper Vehicle—Registration # License # Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant • ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag I Cannery \Paste Site ❑ Sludge/Ask Site ❑'Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA.1andfril Site ❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd Number of Units ❑ FarntlRa.rcz .:,-. ., Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Sldlled Nursing ❑ Large Generator t] Small Generator ❑ y.trtti6 _ <ialer ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—[] 2 -10 ❑ 11- 60 - --❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PN'SEND 46-02-004 Blue Application Form _ EMERGENCY NOTIFICATION FOR THIS FACII-111 ANDIOR PROGRAM CONTACT PERSON Day Ph ight Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date INVOICE # ❑ Cash REVIEWEDBY ACCOUNTING OFFICE Date Masterfile Record Pink