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SAN JOAQUIN COUNTY ENVIRONMENTAL I3EALTII DEPARTI\ZENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility []New Eli Program and New Facility <br /> Facilit •ID 6 S Program Record ID <br /> Facility Address zW (l� <br /> (Please Check the appropriated eription and specify jLze�number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs❑ No❑ <br /> ❑ Commissary ❑ Drystorage 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 /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> H k7ARDOUS WASTE PROGRAM(2200) r <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 ❑Pe 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 forms - <br /> HOVSING PROGRAM(2400) _ <br /> ❑ Hotel/Motel—Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Fmplovee Housinp/Labor Camp Application 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 IIW Site ❑ Don-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑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(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard _ff 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(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 PICS BKD l6-02-003 Blue Appiieation Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT L FEE ❑ Surcharge FEE ❑ Other FEE <br /> lNseecroR# Z PERMIT VALID . to 11 Food Ifandler <br /> ❑ Check s ADIDUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY AccoU TING OFFICE Date e2 <br />