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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT NtASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existing Facility ❑New EH Progmi and New Facility Facility ID Program 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 PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Ilead Unit CUPA ❑ State Facility Surcharge(2399) IIAZARDOUS WASTE PROGRAM(2200) i ❑ hazardous Waste Generator— Tons Generated Per Year ❑ Recycle/Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑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) ❑IloteLlMotel Number of Units ❑Jail or Exempt Institution Number of Units Employee housing(2700)Use F,mployee ffousinglfabor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site ❑Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑RN`'QCB Cleanup Site ❑ Nater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ 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) 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--Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch 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---E] 2- 10--❑ 11-60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PIIS ElID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELFAIENT FEE ❑ Surcharge FEE ❑ Other FEF. INSPECTOR# 2 PERMIT VALID to ❑ Food handler ❑ Check# AMOUNT PAID Date INVOICE# 11 El Cash 1ZEVIE\VEDBY /�fL>J `j �Lr( ACCOUNTINGOFFICE Date V