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SAN JOAQUIN COUNTY Eli ZONMENTAL HEALTH DEPART :NT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facilitv ❑New EH Program and New Facility <br />Facility ID Program Record ID <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ 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 <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event --Dates of operation from 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 />COPA ❑ State Facility Surcharge (2399) G 5 0 <br />HAZARUOU WASTE PROGRA (2200) <br />0Iazardous Waste Generat------------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 ❑ Permit -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 />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution ------Number of Units <br />Employee Housing (2700) Use Employee HousinglLabor 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 HW 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 ❑ 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 # <br />❑ Pumper Yard ❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />CapacityVehicle # <br />❑ Chemical Toilets -------Number of Units <br />❑ Landfill <br />❑ Transfer Station <br />❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility <br />❑ Compost Facility <br />❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles --Number of Units <br />❑ Dumpsters > 20 cu yd ----Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care <br />❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station <br />❑ Veterinary Clinic <br />❑ Common Storage Facility ----- 112-10 ------- <br />❑ 11 - 60 ------ 11 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />Day Ph Night Ph <br />PROGRAM ELEMENT�� a 7� FEE �� p G� — ❑ Surcharge FEE <br />,�,� 11 ❑ Other FEE_ <br />INSPECTOR # � PERMIT VALID ) — % — p to la'a / ' 7l7 ❑ Food Handler <br />❑ Check # ef AMOUNT PAID Date INVOICE # I l l <br />❑ Cash REVIEWED BY <br />ACCOUNTING OFFICE <br />Date 41 <br />48-02-034 Masterfile Record Pink <br />i nr<nnmi <br />