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SAN JOAQUIN COUNTY E IRON-MENTAL HEALTH DEPAR `.ENT <br /> MASTERFILE RECORD I`i-FORtiIATION FORM <br /> Iew EH Prosram at Existing Facility <br /> ❑New EH Program and New Facility <br /> Facility ID �—_ 0 <br /> Program Record ID <br /> Facility Address - <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required: -YES ❑ No ❑- <br /> ❑ Restaurant: Seating Capacity Square Footage <br /> ❑ with Food Preparation <br /> ❑Vending Machines—Number of Units <br /> [I commissary ❑ Dry storage only p <br /> ❑ Retail Market----Square footage Elwith Meat Market only [I Multiple Departments El Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make License' Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑ Temporary Food Facility-----Dates of operation from to 11Produce Stand <br /> ❑ Special Event --Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> 1:1Grade B Dairy [I Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year O —`f ❑ Recycle/Exempt System(2299) <br /> G]/1!Iazardous Waste Generator-------- » ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers(2218) <br /> [I Silver Only(_2_2__) ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Facility 11 Conditionally Authorized(CA) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) N umber and B forms <br /> ST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution---Number of Units <br /> ❑ Hotel/Ni lotel-------Number of Units <br /> Employee Housing(2700) Use EmployeeHousing/Lahor Camp Application Form <br /> UNDERGROUND INJECTION CONTROL(3000) site <br /> UST-CAP Site ❑ Site I H,I „QCB Cleanup❑Site NPL/SEP <br /> UIC Site <br /> El Environmental Assessment ❑ 0 RVater Quality Remediation SITE MITIGATION(2Remediation Site <br /> ❑ Abandoned HW Site <br /> ❑ non-NPL/SEP Cleanup <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> ❑ Pool El Spa ❑ Out of Service Pool/Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC d O RAM (4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle--Registration# ❑ Chemical Toilets-------Number of Units <br /> C1 Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) [ISludge/Ash Site <br /> C1 Transfer Station ❑ Ag/Cannery Waste Site [I CIA Landfill Site <br /> 11 Landfill ❑ Pcess/Recycle Facility <br /> ❑ Waste Tire Facility ❑ Compost Facility ro ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units —__ 11 umber of Units <br /> Dumpsters>20 cu yd ---N <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator 11 Limited Hauler <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator Facility 2- 10"----"-011 -60------❑ >60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> [I Common Storage <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PNS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROG�RAMight Ph <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> [I Surcharge FEE_. <br /> PROGRAM ELEMENT_ FEE to \Z,L7b\I�� ❑ Food Handler <br /> INSPECTOR# � �� PERMIT VALID Date INVOICE# <br /> ❑ Check# AMOUNT PAID Date <br /> BY ACCOUNTING <br /> REVIEWED OFFICE <br /> ❑ Cash Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />