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- • f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Proam at Existing Facility ❑New EH Program and New Facility <br /> FacilityH) ( Program Record ID <br /> Facility Address iSZ'�6 <br /> (Please(deck the appropriate description and specify EjM number of units and Pertinent information) <br /> FOOD PROGRAM(1600) <br /> []Restaurant: Seating Capacity SquareFootage 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 Facitity Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) j <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) _ ❑Appliance ReeyclerS(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ,p ❑Pemut-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> NJ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use U•STA and B loans 5 t W e e hd1�nC of i <br /> a i � � o.i <br /> HOUSING PROGRAM(2400) I I>• <br /> [IHotel/Motel Number of Units [3 Jail or Exempt Institution umber of Units <br /> Employee Housing(2700)Use Employee IfousinKabor Cama Amfication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLlSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site ' <br /> RECREA'11ONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Ppol ❑ 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—Registration# License# Capacity Vehicle# <br /> ❑Pumper Yard . ❑PackageTreatment 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/RecycleFacility ❑ 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 Can ❑Acute Care ❑ Skilled Nursing ❑Large Generator D Small Generator ❑Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--El 2-10—❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS ERD 46-02-003 Biue Application Form <br /> MERGEN Y N IFI ATI ON FOR Tin FACILITY AND/OR PROGRAM <br /> CONTACTPERSONnn�� Day Ph `1 Night Ph <br /> i <br /> PROGRAMELEmcNT s;� FEE ❑ Surcharge FEE ' ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REvrEwWBY 9-q Ul ACCOUNTING OFFICE Date <br />