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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existin Facility ew EH Program and New Facility - <br /> Facility ID Pro ram Record ID PK0eql <br /> Facility Address <br /> (Piettse Check the appropriate description and specify lize,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 ❑ Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ---jjj ❑ 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) f <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑Appliance Reoyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> �/,^ 13Permit-By Rule Filed Unit-_ ❑Permit-By Rule Ho hold Hazardous Waste <br /> � <br /> Z-!-ABOVEGROUND STORAGE TANK FACILITY(ASI�(2390) Number of AST- Lr,w�7.,u-v..rx,a�' "mac-�`–' <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(23;JW e-7�3T-.t and B forms Ptn.9'tiA- '4e 0 0 T. i�/t 107 F . <br /> HOUSING PROGRAM(2400) - <br /> ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F rl*yee Housinje1xbor Camp Apti icirdon Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(3000) . <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned 11W Site ❑non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑Spa 0 Out of Service Pool/Spn ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) - <br /> ❑ Poultry Farm—Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) 0 Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> Liam 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/CanneryWaste 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(Rauch 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--❑ 2-10—1111-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PICS EHD 46-02-003 Mae Appliea(ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE 11 Other FEE <br /> INSPECTOR# �-tCl�� PERMITVAUD - to ❑ Food Handler <br /> ❑ aleck# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWEDBY LT ZtY 0 ACCOuNrINOOFFICE Date <br />