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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DIVISION <br />MASTERFILE RECORD INFORNtiLATION FORv1(EH 00 69) <br />New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID (t -a Program Record ED S <br />Facility Address d(Y'YiI TL <br />(Please Check the appropriate description and specify size, <br />FOOD PROGRAM (1600) <br />number of units and pertinent information.) <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: YEs ❑ No ❑ <br />❑ Vending Machines —Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />E <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 />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 />I)ERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ Jail or Exempt Institution Number of Units <br />❑ HoteUiV[otel------- Number of Units P <br />Employee Housing (2700) Use Employee Housing/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 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 Cl Pool C1 Spa El Out of Service Pool/Spa ❑Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />C1 Poultry Farm Maximum number of birds C1 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />11 Tattooing (412 1) ❑ Body Piercing (4120) C1 Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />C1 Pumper Vehicle—Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />C3 Landfill C1 Transfer Station ❑ Ag / Cannery Waste Site ❑ SludgelAsh 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/Rauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />C1Primary Care C1 Acute Care ❑ Skilled Nursing C3 Large Generator [3 Small Generator Cl Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 -- ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EH0069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM ELEMENT O1 �) C� FEE _ <br />INSPECTOR # _IL/ PER.Nlrr VALID <br />❑ Check # <br />❑ Cash <br />REVTENVED BY <br />EH 0069 PINK FOPUM.doc <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler <br />PAID Date <br />ACCOUNTING OFFICE <br />INVOICE # <br />Date <br />Rev. 07/07/99 <br />