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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPART MZ NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at ExisWg Facility ❑New EH Program and New Facility <br /> Facilit ,ID Pro ram Record ID <br /> r 7- <br /> Facility Address T <br /> (Please Check the appropriate description and specify siz 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 Vehicle Type Color <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 - 11 Ice Plant _ <br /> [ISpecial Event —Dates of operation from to ❑ Produce Stand <br /> - DAIRY PROGRAM(2000) - <br /> _ ❑ 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 ❑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 t-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 o s <br /> HOUSING PROGRAM(2400) - - <br /> ❑HoteUhfotel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Eml*yee 0ousin#/Labor Camp AMMfication Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑ NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑non-NPIJSEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool 13 Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <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 /> ❑ Pamper 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 ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4$00) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10—❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EIID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON / Day Ph Night Ph <br /> PROGRATt ELEMENTZ S EE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# lT VALID . to ❑ Food Handler <br /> ❑ CheckAMOUNT PAID Date INVOICE# <br /> 101 Cash REVIEWED BY ACCOUNTING OFFICE Date al2z es <br /> bheP�lr R",cl pink <br />