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SAN JOAQUIN COUNTY AWONMkNTAI,HEALTH DEPARiTWNT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facie ❑New EH Program and New Facility Facility ID Pro am Record ID Facility Address (Please Check the appropriate description and specify size,number of not and Pertinent information.) FOOD PROGRAM(1600) ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required: Yes❑ No❑ ❑ 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 Dispeowr--Number of Containers in Multi-Head Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) Hazardous Waste Generator---------Tons Generated Per Year ` TCwS 13 Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) Tiered Permitting Facility-----13 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 UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)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 finoloree Housing/Labor Carrm Apolicadon 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 She ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROORAM(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) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle--Registration# License# Capacity Vehicle# 13 Pumper Yard ❑Package Treatment Plant 11 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 Can ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---02- 10------❑ 11-60---❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 4602-003 Blue Aonlieadyn Form EMERGENCY NOTIFICATION FOR TNIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑Other FEE INSPECTOR# PERhnT VALID to ❑Food Handler ❑Check# AMOUNT PAID Date INVOICE# ❑ Cash REv1EwED sy AccouNnNo OFFICE Date 48-02-034 Masterfile Record Pink 10/6/2003