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SAN JOAQUIN COUNTY , BRONMENTAL HEALTH DEPAR ENT MAS`[`ERFILE RECORD INFORMATION FORM ❑ New ISH Program at Existing Facility ❑New EH Program and New Facility FacilijX ID 12 S Pro ram Record ID 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 ❑ ❑ 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-PRO_GRAM(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 ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) -- ❑ Silver Only(2222) ❑ Appliance Recyclers(2237) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste XAIUNDERGROUND BOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST a 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 Applica#fon Form SITE MITIG TION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONALHEALTH PROGRAM(3600) Number of Pools/Spas at Facifty ❑ Pool ❑ Spa ❑ Out of Service PooUSpa ❑ 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) UCLUID WASTE PROGRAM(4200) I ❑ 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 w of Units) ❑ Dumpsters y 20 cu yd R of Units) ❑ Farmffianch 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 46-02-00.3 Blue Anjollcatlon Form EMERGENCY NOTIFICATIQN FOR THIS FACILITY ANOIOR PROGRAM k CONTACT PERSON Day Ph Night Ph ' PROGRAM ELEMENT 2- 3 P FEE ❑ Surcharge FEE ❑ Other FEE #NSIaEcroR#,C-1- �- , PERMIT VALID to ❑ Food Handler 13 Check# AMOUNT PAID Date INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Dateal- Q 6 48-02-034 MASTERFILE RECORD INFORMA'nON PINK 11/15/07