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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATI FORM I v D <br />❑ New El I Program at ExistingFacility New EH Program and New Facility <br />Facility ID &90 Ik J IV 0 Program Record ID _ �I <br />Facility Address <br />(Please Check the appropriate description and specify��1 9�� <br />W n� r <br />u'mber of units and ertinent infor ati n.) � -W . <br />FOOD PROGRAM (1600) 1 ,�-�-C LV u i- <br />❑ Restaurant: Seating Capacity Square Footage Food handlers Course required: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending 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 <br />❑ Special Event -Dates of operation from to_ <br />to <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2NO) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) <br />❑ hazardous Waste Generator. Tons Generated Per Year ❑Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) <br />Ti red Permitting Facility 11 Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Unit ❑ ermit-By-Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Numbcr of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B fo <br />HOUSING PROGRAM (2400) <br />❑ Ilotenlotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employ" housing (2700) Use Employee IlousinZ/ abor 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 11W 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 11 Kennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4 120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle -Registration # License # Capacity <br />Vehicle# <br />❑ Chemical Toilets <br />❑ Pumper Yard ElPackage Treatment Plant ic <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles -Number of Units ❑ Dumpsters > 20 cu yd --Number of Units <br />❑ Firm/Rauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care ❑ Acute Care ❑ Skilled Nursing 11 Large Generator ❑ Small Generator ❑ Linuted Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -0 2 - 10 <br />❑ 11 - 60 -----❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PMS EffD46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph <br />Night Ph <br />PROGRAM ELEMENT FEE ❑ Surcharge FEE <br />❑ Other FEF. <br />INSPECTOR # P17 MIT VALID to <br />❑ Food handler <br />❑ Check # Date <br />INVOICE # <br />❑ Cash RE -VIEWED 13Y A OUNTING OFFICE <br />Date �v <br />