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SAN JOAQUIN COUNTY EI�.RONNIENTAL HEALTH DEPAR',.ENT MASTERFILE RECORD INFORMATION FORM ew EH Pro rrant at Existing Facili ❑New EH Prroo am and�N7eew Facili Facilit ID Program Record ID (/✓Z. 7"1 Facility Address (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 ❑ 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) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit CUP A ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Generated Per Year Cl Recycle/Exempt System(2299) ❑ CRT Offsite Handlers (221 s) ❑ 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)(2X) Number of AST ( UNDERGROUND STORAGE TANK(UST)PROGRAM( 0)Use UST A and B forms HOUSING PROGRAM(2400) _ ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700)Use Emplovee HousinelLabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--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--Number of Units ❑ Dumpsters>20 cu yd----Number 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-------011 -60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form �7 EMERGE Y NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 461`'11 4y—t Day Ph 73!1— 2 5 3 Night Ph PROGRAM ELEMENT ^�2 S FEE 11 Surcharge FEE C3 Other FEE INSPECTOR# J &� Gi PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWEDBY �� S ACCOUNTING OFFICE Date V 48-02-034 Masterfile Record Pink 10/6/2003