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V SAN OAQUTN COUNTY ENVIRONMENTAL HEALTH DERV TII NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New Eli Pro and New Facility <br /> ❑New Eli Program at Existin Facility � <br /> Facilif"ID <br /> Program Record ID <br /> Facility Address <br /> n and specify <br /> (Please Check the appropriate descriptios'u number of units and per#iaent information.) <br /> FOOD pRoGRAM(1600) Food Handlers Course re uireds- Yrs❑ No 130 Restaurant: Seating Capacity Square Footage . <br /> Oven, Machines Number of Units�__ <br /> © Commissary Dry storage only ❑with Food Preparation b ed Goods Onl <br /> ❑Retail Commissary <br /> market----Square footage ❑with Meat Market only ❑Multiple Departments ❑prepackaged y <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑Mobile Food Prep Unit—Make License# Sticker# <br /> Registration# to ❑ Ice Plant <br /> ❑Temporary Food Facility Dates of operation from ❑Produce Stand <br /> ❑Special Event --Dates of operation from <br /> to <br /> DAIRY PROGRAM(2000 <br /> ❑ Grade B Dalry ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy <br /> �CUPA ❑ State Facility Surcharge(2399) i <br /> HAZARDOUS WASTE PROGRAM(2200) ©Recycle/Ezecnpt System(2299 <br /> ❑ hazardous Waste Generator. Tons Generated Per Year A fiance Reeyclers{2217) <br /> [I CRT Offsite Handlers(2219) ❑Silver Only(2222) -- P <br /> Tiered Permitting Facility ©Conditionally Authorized(CA) Con 'tionally Exempt(CE) <br /> LL ll ❑Permit By Rule Fixed Unit Pe ' -By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST�!and B a s <br /> HOUSING PICOGRAM(2400) <br /> or E <br /> ❑Ja <br /> [3 IIotel/Motel Number of Units ilExempt tution Number of Units <br /> l mployee Housing(2700)Use FE l0 A0 six /Labor Com rt lication Form <br /> SITE MITIGATION(2900) - UNDERGROUND IN.IECTION CONTROL(3000) <br /> .❑ Environmental Assessment [3 UST-CAP Site 11 Local UW Cleanup Site. El NPL/SEP Cleanu Site 13 UIC Site <br /> 0 Abandoned HW Site ❑uon-NPLISEP Cleanup Site ❑RWQCB Cleanup Site "❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3640) <br /> Number of Pools/Spas at Facility. ❑Pool L3 spa ❑out of Service PoolfSpa T3 Natural Bathing Area <br /> VECTOR.CONTROL PROGRAfUt(4000) ❑Kennel <br /> ❑Poultry Farm Maximum number of birds <br /> TATTOO BODY PIERCING PERMAmr=NT COSMETIC PROGRAM(4100) [}Permanent Cosmetics(4122) <br /> ❑Tattooing(4121) Cl Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> [3 pumper Vehicle—Registration# License# Capacity <br /> ❑Pumper Yard . 13 Package Treatment Plant, ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> CIA /Cannery Waste Site ❑SludgdAsh Site <br /> ❑ Landfill ❑Transfer Station g ry <br /> [I Waste Tire Facility 0 Compost Facility L1ProcesslRecycle Facility ❑ CiA Landfrll Site <br /> ❑Refuse Vehicles Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator I� Small Generator ❑ Limited Iiauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4640)Use PWS EAD46-02-003 $[rreA licationForm <br /> F-MERGENCY NOTIFICATION r:oR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> ]PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPEC OR# PERMIT VALID . to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIF-WEDBY ACCOUNTING OFFICE Date ac.L <br /> 11,f acs.-�7�Rvrnrrl Pink <br />