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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existi¢ Facility <br /> ❑New EH Program and New Facility <br /> Facilif ID Pro ram Record ID <br /> Facility Address <br /> (Please Check the appropriate descriptio¢and specify size,number of units and Pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. No 13. Yes❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines Number of Units <br /> El Retail Market—Square footage ❑with Meat Market only [3 Multiple Departments [I Prepackaged Goods Only <br /> Vehicle Type Color - <br /> ❑ Mobile Food Vehicle—Make License# Sticker# <br /> Registration# Color <br /> ❑Mobile Food Prep Unit—Make Vehicle Type <br /> Registration# License# Sticker# <br /> to 13 Ice Plant <br /> ❑Temporary Food Facility—Dates of operation from [I Produce Stand <br /> [3 Special Event —Dates of operation from tO <br /> DAIRY PROGRAM(2000) <br /> ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑Grade A Dairy ❑ Grade B Dairy <br /> --CUPA ❑State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) t <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 Household Hazardous Waste <br /> I7 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 /> ❑HoteUMotel—Number of Units ❑Jail or Exempt Institution—Number of Units _ <br /> Employee Housiag(2700)Use P'^^lop^^/fousirse/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> -❑ Environmental Assessment [IUST-CAPSite ElLocal HW Cleanup Site. 13NPIISEP Cleanup Site [3 UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pocls/SPas at Facility 11 pool [3 spa 11 Out of Service Pool/Spa ❑Natural Balding Area <br /> VECTOR, ONTROL PROGRAM(4000) ❑ Kennel <br /> ❑Poultry Farm—Maximum number of birds <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# License# Capacity Vehicle-# <br /> 11 Pumper Yard ❑ Package TreatmentPlaut ❑ ChemicalToilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 13 Transfer Station ❑Ag/Cannery Waste Site 1:1 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/Ra¢ch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 13 Primary Care El Acute Care ❑ Skilled Nursing 13 Large Generator 13 Small Generator 11 Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS EIID 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# _ PERMIT VALID . to ❑Food Handler <br /> ❑ check# AMOUNT PAID Date INVOICE# <br /> 0 CaSh REVIEWED By ACCOUNTING OFFICE Date <br />