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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit ID <br /> Program Record ID <br /> Facility Address rnVJiAak4 <br /> (Please Beck the appropriate description and specify sing number of units and pertinent information.) <br /> FOOD PROGRAM(1600) - <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YEs❑ No 11❑ Commissary 11 Dry storage only ❑with Food Preparation ❑Veadiag 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 ❑ lee 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 /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t <br /> ❑ Hazardous Waste Generator Tons Generated Per Year ❑Recycle L 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-Ride Fixed Unit ❑�t-By-Rule Household Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> ✓✓✓✓ TUtINDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel—Number of UnitsElJail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee HousinrlLabor Camp Appficalioa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local MV Cleanup Site. ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑Abandoned MY Site ❑non-NPLLSEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Poots/Spas at Facility ❑P901 ❑ 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(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle—Rogistration# 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 eu yd—Number of Units ❑FarmtRauch 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--❑ 2-10—❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHIS ELM 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR TNIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEbIFNT Z a gZ FEE ❑ SurchargeFEE ❑ Other FEE <br /> INsescrOR# PERMIT VALID . l to C L ( ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> •----1 W.,tfile Record Pink <br />