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SAN JOAQUIN COUNTYL,-�"IRONMENTAL HEALTH DEPAr� ';:'.NTT] <br /> MASTERFILE�-RECORD INFORMATION FORM <br /> ❑ New EH Pro ram at Existin acilitz ❑New EH Program and New Facility <br /> Facility ID1 Program Record ID <br /> Facility Address AV <br /> (Please check the appropriate description and specify size,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 TypeColor <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 11 Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 111 Grade A Dairy ❑ Grade B Dairy ❑ 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 <br /> ❑ 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 /> 11Permit-By-RuleFixed Unit ElPermit-By_R a ousehold Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number ofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700) Use Em to ee Housing/Labor Camp Anofication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ocal HW 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 ❑ pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) I <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) f <br /> ❑ Pumper Vehicle Registration# License# r <br /> 11Pumper Yard Capacity Vehicle# <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Package Treatment Plant C1Chemical of Chemical Toilets---Numberf Uf <br /> ❑ Landfill <br /> 13 Transfer Station <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Ag/Cannery Waste Site <br /> ❑ Process/Recycle Facility <br /> Sludge/Ash Site <br /> ❑ Refuse Vehicles(#of Units) y ❑ CIA Landfill Site <br /> MEDICAL WASTE PROGRAM(4500) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch Cleanup Site <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ' <br /> 13Transfer Station 11Veterina Clinic ❑ Small Generator ❑ Limited Hauler <br /> ry ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 <br /> PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS E14D 46-02-003 01_A 6tation Form E3 �60 generators <br /> CONTACT PERSON EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> PROGRAM ELEMENT FEE Day Ph Night Ph <br /> INSPECTOR iyL°� t< ❑ Surcharge FEE ❑ Other FEE <br /> PERMIT VALID to <br /> ❑ Check# AMOUIVr Pao ❑ Food Handler <br /> ❑Cash Date 0 INVOICE# <br /> REVIEWED BY ACCOUNTING OFFICE <br /> Date <br /> 48-02-0s4 <br /> 11115107 MASTERFILE RECORD INFORMATION PINK <br /> cun�a_ni � I `• as sunv�`.�`.;RM <br />