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JOAQUIN COUNTY ENNMENTAL HEALTH DEPART T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing FadW ❑New EH Pro am and New Facility <br /> Facilit H) �O 11 Pro ram 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 13 NO ❑ -- ----- <br /> ❑ Commissary ❑ Dry storage only 11 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 <br /> to ❑ Ice Plant <br /> ❑ Special Event --Dates of operation from <br /> 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 Cl State Facility Surcharge(2399),.._ - <br /> HAZARDOUS WASTE PROGRgM(2200 <br /> 'Hazardous Waste Generator------------Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(22 17) <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 HoasinE/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 ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm--Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Vehicle# <br /> El Pumper Vehicle--Registration# <br /> License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets-----Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Site <br /> 11 Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site g <br /> ❑ Process/Recycle Facility ❑ CIA Landoll Site <br /> 11 Waste Tire Facility [I Compost Facility ❑ Farm/Ranch Cleanup Site <br /> 11 Refuse Vehicles--Number of Units ElDumpsters>20 cu yd---Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---D 2-10------❑ 11 -60------11 >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> eFEE ❑ Other FEE <br /> PROGRAM ELEME\T PCZ Z ❑ Surcharge FEE // g ❑ Food Handler <br /> INSPECTOR# _, PERMITVALID llI kil to 0, <br /> ❑ Check# AMOUNTPAID e>st-�.Cyj Date INVOICE <br /> ❑ Cash REVIEW ED BY <br /> ACCOUNTING OFFICE Date I:,-L((d <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />