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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Pro am at Existing Facility ❑New EH Program and New Facili <br /> Facilit ,ID I V U , IProgram Rpcord ID <br /> Facility Address 2 LOC) <br /> (Please Check the appropriate description and specify jjKr,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage 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—Dates of operation from to ❑ Ice Plant <br /> ❑Special Event —Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ Slate Facility Surcharge(2399) <br /> HAZARDOUS IVASTE PROGRAM(2200) I r <br /> ❑Hazardous Waste Generator— Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(22 18) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) nditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit P t-By-Kole Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and o <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotel/Motel—Number of Unit ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Fmplopee Ilousinp/Labor Camp Anplirnrian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned I1W Site ❑non-NPL(SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool 13 Spa C1 Out of Service Pool/Spa ❑ Natural Bathing Arca <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 If License# Capacity Vehicle If <br /> ❑Pumper Yard ❑ PackageTreatmentPlant ❑ ChemicalToilets—NumlraofUnit <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station El Ag/Cannery Waste Site ❑ SludgdAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ Proms/Recycle Facility ❑ CIA Laadfdl Site <br /> ❑ Refuse Vehicles—Number of Unit ❑ Dumpsters>20 cu yd—Number of Unit ❑Farm/Raocb Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator [:] Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10—❑ 11 -60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PICS EffD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROD RAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT L FEE ❑ Surcharge FEE ❑ Other FEF. <br /> INSPECTOR# ?i EkMfrVAUD . to ❑ Food Handler <br /> El Check AMOUNT PAID Dale_ INVOICE# ^ n <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date v <br /> M..y..GI•V�,r pink <br />