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R SAN JOAQUIN COUNTY EN`__,ONMENTAL HEALTH DEPART,._JNT MASTERFILE RECORD INFORMATION FOR-NI Ez\ew EH Program at Existing Facility ❑New EH Program and New Facility Facilitv ID D)r D U Program Record ID Facility Address b" (Please Check the appropriate descriptiand specify size'number of units and pertinent information.) 1 FOOD PROGRAM(1600) El Restaurant: Seating Capacity Square Footage Food Handlers Course re u d: Es i O El Commissary El storage only ❑ with Food Preparation ❑Vending Machines--Number of its ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ P packaged Goods Only ❑ Mobile Food Vehicle-----Make Vehicle Type Co r Registration# License# Stic # ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# ticker# ❑ Temporary Food Facility-----Dates of operation fr to ❑ Ice Plant ❑ Special Event --Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser--7erof Containers in Multi-Head Unit CUPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ Hazardous Waste Generator------------Tons Gen ra Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver my(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility--------------- ❑ Condition lly Authoriz (CA) ❑ Conditionally Exempt(CE) ❑Permit-By- ule Fixe nit ❑ Permit-By-Rule Household Hazardous Waste ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390 N ber of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) s UST A and B forms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units it or Exempt Institution-----Number of Units Employee Housing(2700) Use Employee Housin /Labor Cam A licati Form SITE MITIGATION(2900) UNDERG UND INJ CTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Loc 1 HW Cleanup ite ❑ NPL/SEP Cleanup Site ❑ UIC Site Cl Abandoned HNN'Site ❑ non-NPL/SEP Cleanup S' e ❑ RWQCB leanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool Spa ❑ Out o Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSM IC PROGRAM(4100) ❑ Tattooing(412 1) /Cility dy Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200 ❑ Pumper Vehicle--Registration= License# Capacity Vehicle# ❑ Pumper Yard eatment Plant ❑ Chemical Toilets------Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Tra ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ZLWaste Tire Facility ❑ Co ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles--Number of kn ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(45❑ Primary Care ❑ Acute Cled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterina ❑ Common Storage Facility-----❑ 2 l0--- ❑ I I -60------11 >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Applicafion Form EMERGENCY N IFICATION FOR THIS FACI AND/OR PROGRAM CONTACT PERSON Day P Night Ph PROGRAM ELEMENT v FEE -(25 Surcharge FEE ❑ Other FEE INSPECTOR# �0�(� PERMIT VALID a to&�p 0 ❑ Food Handler ❑ Check# AMOUNT PAID ate INVOICE# ❑ Cash REVIEWED BY AcCOLUNTING OFFICELA Date al rltT 48-02-034 Masterfile Record Pink 10/6/2003