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S,y�ufYbigyb - t,t_.„ d i h i-'i SANI JOAQUIN COUNTY EN: ONMENTAL HEALTH DEPART NT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at ExistingFacili ❑New EH Program 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-Head Unit COPA ❑ 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(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) ❑Hotemotel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Emplv)w Housing/Labor 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 HW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas 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(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 ❑ SiudgetAsh Site ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA Landfill Site 0,Refuse Vehicles—Number of Units 1 rL6 � ' ❑Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) -f,71) C t t) ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-13 2-10 ❑ 11-60------❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANOtOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑Surcharge FEE ❑ Other FEE INSPECTOR# (j C4212 PERMIT VALID /� to ❑Food Handler 11dt/✓C-Check# AMOUNT PAID M , L f) 4 Q� INVOICE# ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 Masterfile Record Pink t oifinool