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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New Eli Program and New Facility <br />Facility ID (��% ® _� Pro ram Record ID b —5 <br />Facility Address <br />(Please Check the appropriate description and ecify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food handlers Course required:. Yrs ❑ 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 <br />Registration # <br />❑ Mobile Food Prep Unit—Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation from <br />❑ Special Event —Dates of operation from <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Vehicle Type <br />License # _ <br />Vehicle Type <br />License # <br />to <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator. Tons Generated Per Year❑Recycle /Ezempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) _ ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste <br />❑ ABOVEGROUND 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 />[I IIotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Employee IlausinZ/Ubor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned I1W Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool El Spa ❑ Out of Service PooUSpa ❑ Natural Bathing Area <br />VECTOR.CONTROL PROGRAM (4000) <br />❑ Kennel <br />❑ Poultry Farm Maximum number of birds <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />El Pumper Vehicle—Registration # License # Capacity <br />Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station 11 Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />[3 Primary Care ❑ Acute Care ❑ Skilled Nursing 11 Large Generator ❑Small <br />Generator 11 Limited hauler <br />11 Transfer Station 13 Veterinary Clinic ❑ Common Storage Facility --0 2 - 10 <br />❑ 11- 60 - — ❑ > 60 generators <br />PUBLIC WATER SYSTEM_ PROGRAM (4600) Use PIES EHD 46-02-003 Blue Application Foran <br />EMERGENCY NOTIFICATION FOR TIits FACILITY ANDIOR PROGRAM <br />CONTACT PERSON Day Ph <br />Night Ph <br />PROGRAM ELEMENT FEE 11Surcharge Fee <br />ElOther FEE <br />INSPECTOR # PERMIT VALID to <br />❑ Food Handler <br />❑ Check # AMOUNT PAID Date <br />INVOICE # <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE i l <br />Date <br />