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SAN JOAQUIN COUNT NVIRONMEN'iAL HEALTH DEP! 7MENT MASTERFILE RECORD INFORMATION FORM Lq New EH Pro ram at Existin Facili ❑New EH Program and New Facilit Facility ID �} (XW318' Program Record ID Facility Addresses Lt) . ( Q� ✓e (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 ❑ ❑ 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 Ice Stan ;` .DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit.` COPA ❑ State Facility Surcharge(2399) ' HAZARDOUS WASTE PROGRAM (2200) CRT Offsite Handlers 2218 ---- ❑ Silver Only 2222 L�' ❑ Appliance.. u . Hazardous Waste Generator----------- Tons Generated Per Year ❑ Recycle/Exempt System(2299)-" ( ) -- Y( ) Recyclers(2217) - Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) =a ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Houset)old HJaza{�N �ltaste k ❑ 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 Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL_(3000) - ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site Cl Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup:Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of PooWSpas 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(4 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 1:12- 10 011 -60 ❑ >60 generators ` PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM } CONTACT PERSON _ Day Ph Night Ph PROGRAM ELEMENT2 FEE ❑ Surchar *FEE ❑ Other FEE INSPECTOR# � PERMIT VALID S ; I i t0 I 1 I ) ❑ Food Handler_ "fY 13 Check# AMOUNT PAID Date jr, i INVOICE# � 12 Cash REVIEWED BY So -D)—) ACCOUNTING OFFICE �:1 Date 48-02-034 MASTERFILE RECORD INFORMATION PINK' 11/15/07