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SAN JOAQUIN COUNTY ENVIRONMENTAL JJEALTII DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existin Facility ❑N rog <br />Facility ID 1 Pro ram�ReccorID <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and nertin <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market —Square footage ❑ with Meat Market only <br />❑ Mobile Food Vehicle ----Make Vehicle Type _ <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type _ <br />Registration # License # _ <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event —Dates of operation from to <br />Food Handlers Course required:. Yss n No ❑ <br />❑Fending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ 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) <br />❑ Hazardous Waste Generator. Tons Generated Per Year <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) <br />❑ Permit -By Rule Fixed Unit <br />BOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST <br />DERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel Number of Units ❑ Jail or Exempt <br />Employee Housing (2700) Use Employ <br />A'ousina/Labor Camp Application Form <br />❑ Recycle / Exempt System (2299) <br />❑ A ante Recyclers (2217) <br />O nditl ally Exempt (CE) <br />❑ Termit-B Rule Household Hazardous Waste <br />nber of Units <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30W) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. [3NPL/SEP Cleanup Site [I UIC Site <br />❑ Abandoned IIW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds — <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # _ <br />❑ Pumper Yard <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />License # Capacity Vehicle# <br />❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIALandfill Site <br />❑ Refuse Vehicles —Number of Units <br />❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ FarnvTauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />13 Primary Care ❑Acute Care ❑ Skilled Nursing ❑ Large Generator [I <br />Small Generator ❑ Limited Hauler <br />11Transfer Station [3Veterinary Clinic <br />[ICommon Storage Facility --0 2 - 10 <br />❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use <br />Plf'S FHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br />CONTACT PERSON <br />Day Ph <br />Night Ph <br />PROGRAM ELEMEI .FEE <br />aroma--,- <br />11 SurchargeFEE <br />11Other FEE <br />INSPECTOR# If ERMIT VALID <br />to <br />❑ Food Handler <br />❑ Clieck # AMOUNT PAID <br />Date <br />INVOICE # <br />0 Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Date iB p2 0 <br />