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SAN JOAQUIN COUNTY.'�`MRONMENTAL HEALTH DEPAR TENT MASTERFILECORD INFORMATION FORM Nq [3 New EH Program at Exi tin Facilit ❑New EH Pro ram and New Facility Facilit ID Program Record ID r Q Facility Address D 51 ` to (Please check 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 11 El Commissary.❑ Dry storage only 13with 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 El Ice Plant ❑ Special Event Dates of operation from to 13 Produce Stand DAIRY PROGRAM!(2000) ❑ 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-R M. 0 usehold Hazardous Waste .k1ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and S forms HOUSING PROGRAM(2400) &/) ❑ Hotel/Motel=Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use Em to ee Housing /Labor Cam APplication Form SITE MITIGATION'(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) 13 Body Piercing(4120) 13 Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehiCie 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 Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE'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 WATER SYSTEM PROGRAM (4600)Use PWS EHD 46-02-003 Slue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT Z FEE ElSurcharge FEE 11Other FEE INSPECTOR#C'•6:2 I10q PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date o2 48-02-034 MASTERFILE RECORD INFORMATION PINK 11/15/07 I