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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Pro am at Ezistin Facility []New EH Proom and New Facility <br /> Facility ID Q o d 39-EP3 Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify EjM number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Drystorage only ❑with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type Color _ <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility—Dales of operation from to ❑ Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade Dairy ❑ Grade B Dairy Cl Milk Dispeaser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) _ y' <br /> ❑Hazardous Waste Generator. Tont Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pettit-By-Rule Fixed Unit ❑Permit-By-Rule,Household Hazardous Waste <br /> 4ABOVEG40UND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) _ <br /> ❑ Rotel/Motel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Rousing(2700)Use Employee)fousinp/Labor Camp Apptiordon Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION C2NTR0L(3000) <br /> ❑ Environmental Anessment ❑UST-CAP Site ❑Local RW Cleanup Site, ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa 17 Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) - ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard . ❑Package Treatment Plant, ❑Chemical ToiletsNumba of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 11 Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator [] Limited Bauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-4] 2-10—1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff'SBUD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION roR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELEhiEN,r FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ��� PERMIT VALID . to ❑Food handler <br /> ❑ Check# AMOUNT PAID Date A INVOICE# q <br /> 0 Cash REVIEWED nY ACCOUNTING OFFICE Date -(/ <br />