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ESAN JOAQUIN COUNTS IRONMENTAL HEALTH DEPARENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facilit ❑New EH Program and New Facility Facilit ID d lj Program Record ID Facility Address (Please check the appropriate description and specify size, number of units and Pertinent information.) El FOOD PROGRAM (1600) Food Handlers Course required: Yes ❑ No ity Square Footage _ � stora a onl ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Restaurant: Seating Capac ❑ Commissary ❑ Dry g y [j with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only [3Retail Market---Square footage Vehicle Type Calor ❑ Mobile Foad Vehicle--Make License# Sticker# Registration# Vehicle Type Make Sticker Color # ❑ Mobile Food Prep Unit License# [I ice Plant Registration# to ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand ❑ Special Event Dates of operation from } DAIRY PROGRAM (2000) ❑ Milk Dispenser-Number of Containers in Multi-Head Unit 0 Grade A Dairy ❑ Grade B Dairy CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Recycle/Exempt System(2299) 11 Hazardous Waste Generator----------- Tons Generated Per Year ❑ App Appliance Rec lers(2217) ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) i Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit 11 permit-By, ousehDld Hazardous Waste ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM (2300)Use UST A and B form HOUSING PROGRAM (2400) ❑ Hotel/Motel----Number of Units C3 Jail or Exempt Instituti0 -- mt)er of Units f Employee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) F ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site I RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area t VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing(4121) ❑ Body Piercing(4120) Cl 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(#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 Blue Agplication Form I EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT 7- FEE C1Surcharge FEE 13Other FEE INSPECTOR#e'R 1P hIP1PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 11115/07