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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART112ENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID Pro ram Record ID <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and pertinent information.y <br />FOOD PROGRAM (160 0) 1 <br />11 Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes ❑ No ❑ <br />❑ Commissary 11 Dry storage only ❑ with Food Preparation ❑Fending 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 <br />Registration # License # _ <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility -----Dates of operation from <br />17 Special Event —Dates of operation from to. <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser ---Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ 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 />❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Ho hold Hazardous Waste <br />�BOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST �� 0 , 8 <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 Employee Housinz/Ubor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment [3UST-CAPSite 11 Local RV Cleanup Site. 11NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned MY Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />❑ Out of Service Pool/Spa ❑Natural Bathing Area <br />Number of Pools/Spas at Facility ❑ Pool 11 Spa <br />VECTOR.CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds 11 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 # _ <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle# <br />❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill 13 Transfer Station 13 Ag / Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ FarnuTanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 - 10 ❑ 11- 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Plf'SE11D 46-02-003 Blue Application Form <br />CONTACT PERSON <br />PROGRAM ELEMENT <br />INSPECTOR # <br />❑ Check # <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph Night Ph <br />FEE <br />PERMIT VALID . <br />MIOUNT PAID <br />0 Cash REVIEWED BY <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE #, <br />Date 7 <br />