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SANT AQUIN COUNTY E10RONMENTAL HEALTH DEPAR ENT MASTERFILE /-RD IN O TION FORM New EH ro am at ExistingFacilitytoy ❑New EH Pro am and New Facility Facili ID Pro Record ID Facility kddress A' (Please Chem the appropriate description and specify size'number of units and Pertinent information.) FOOD PR GRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ ❑ Commis ary ❑ 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 I ood Prep Unit--Make Vehicle Type Calor Registration# License# Sticker# ❑ Tempor ry Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special I vent --Dates of operation from to ❑ Produce Stand DAIRY PR IGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HZ OUS WASTE PROGRAM(2200) .I� azardous Waste Generator------------Tons Generated Per Year A El Recycle/Exempt System(2299) RT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tie ed 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 UN ERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B forms HOUSING ROGRAM(2400) ❑ Hotel/M tel-------Number of Units ❑ Jail or Exempt Institution------Number of Units Employee Ho ising(2700) Use Employee HousinelLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environ nental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandot ed HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATI NAL HEALTH PROGRAM(3600) Number of P ols/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR C DNTROL PROGRAM(4000) ❑ Poultry arm----Maximum number of birds ❑ Kennel TATTOO ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooin (412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID W STE PROGRAM(4200) ❑ PumperVehicle--Registration# 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 T e Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse N ehicies--Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/RaDch Cleanup Site MEDICAL I VASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑ >60 generators PUBLIC Wj LTER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON n n Day Ph Night Ph FSPERI LEMENT v"2� FEE ❑ Surcharge FEE ❑ Other FEE PERMIT VALID (O-l�-10-7 toJ1L-T7l'�O') ❑ Food Handler AMOUNT PAID Date INVOICE# REVIEWED BY W-tuACCOUNTING OFFICE Date L7D�r_ 48-02-034 Masterfile Record Pink 10/6/2003