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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTA NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at EXsfin Facility ❑New EH Program and New Facility <br /> Facility ID <br /> Pro rata Record ID or� <br /> Facility Address <br /> (Please Check the appropriate description and specify gKe,number or 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 ❑'ending Machines Number of Units <br /> ❑ Retail Market--Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> 13Mobile Food Vehicle---Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> 13 Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# Licchse# 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(2040) i! <br /> _ ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi Head Unit <br /> F CUPA ❑ State Facility Surcharge(2399) <br /> JU7-ARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator. Tans Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(22 is) ❑Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit 13 t By Rulc Household Hazardous Waste <br /> J ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> / r UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use FIST A and B o <br /> HOUSING PROGRAM(2400) <br /> ❑Iiotel/Motel Numbcr of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Em to ee Housin lLabor CEMP A fieal:on Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> -C] Environmental Assessment E3 UST-CAP Site 11 Local HW Cleanup Site. ❑NPLISEP Cleanup Site 13 UIC Site <br /> Cl Abandoned HW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolsfSpas at Facility. ❑PQoi ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ©Kennel <br /> TATT00 BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) it <br /> ❑ Tattooing(412 1) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle--Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ©Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility 11 Compost Facility 13ProcessMecycle Facility ❑ ClA Landfill Site <br /> ❑Refuse Vehicles Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑FarullRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-10 ❑ 11-60 3© >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD_46-02-003 glueAWficafion Form <br /> EMERGENCY NOTIFICATION FOR Trus FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEWN''T E ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# II ALID to 11 Food handier <br /> ❑ Check# AmOUINT PAID Date INVOICE# <br /> El Cash REVIEWED BY ACCOUNTING OFFICE Date Of <br /> -- __. a��rfilP Rrrnrrl Pink <br />