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SAN JOAQUIN COUNTY ENVIRONMENTAL IiEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH PLograrn and New Facility <br /> Facilit•ID R 9 9. Pro ram Record ID F <br /> Facility Address �I 0 m)e <br /> (Please Check the appropriate description and specify Size,number of units and pertinent information) _ <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food IIandlers Course required: YEs❑ No❑ <br /> ❑ Commissary ❑Drystorage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility---Dates of operation from - to ❑ Ice Plant _ <br /> ❑ Special Event —Dates of operation 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 Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fined Unit ❑Pe y-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> /V UNDERGROUND STORAGE TANK(UST)PROGRAM(2301)Use UST A and B forms! Z1 <br /> HOUSING PROGRAM(2400) _ <br /> ❑Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Ito u sin g(2700)Use F. PlOPee Housin&LaborCamp ApplicationForm <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-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) - <br /> ❑Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT 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 ofUnits <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ FarmManch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Ilauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility-13 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIPS EUD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON ,,. Day Ph Night Ph <br /> PROGRAM ELEMENTO! <br /> _2 D740 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# % <br /> /-01 PERMITVALID to ❑ Food handler <br /> ❑ Check# AMOUNT PAID Date l INVOICE# <br /> 0 Cash REVIEWED BY ACCOUNTING OFFICE Date <br />