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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Program Record ID v` Z 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 11Retail Market ----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle ---Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit—Make Vehicle Type Registration # License # ❑ Temporary Food Facility -----Dates of operation from to ❑ Special Event —Dates of operation from to _ Color Sticker # _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (20W) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) IIAZARDOUS 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 M_ABOVEGROU�D STORAGE TANK FACILITY (AST) (2390) Number of AST UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B (owns HOUSING PROGRAM (2400) ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee 11ousin,e/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local I1W Cleanup Site, ❑ NPLJSEP Cleanup Site ❑ UIC Site ❑ Abandoned IIW Site ❑ non-NPLISEP 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 ❑ 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/Ranch 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 --0 2 -10 ❑ 11 - 60 ----❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use Pff'S EFID 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM �s� ELEMENT Pc �S % FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR # PERMIT VALID to ❑ Food Handler ❑ Check # A -MOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date Lr!