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, l <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ew EH Program at Existin Facility ❑New EH Pro and New Facility <br /> Facilit•H) Program Record ID c3 <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 CapacitySquare Footage Food Handlers Course required: Yrs❑ NO❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑fending Machines—Number of Units <br /> ❑Retail Market—Square footage- 11 with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ElMobile Food Vehicle—MakeVehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑Temporary Food Facility—,Dales of operation from - to 11 Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) : n " <br /> in Multi-Head Unit <br /> ❑ Grade Dairy 13 Grade B Dairy [I Milk Dispenser—Number of Containers <br /> CUPA (] State Facility Surcharge(2399) <br /> HA7.A#LDOUS WASTE PROGRAM(2200) <br /> Iazardous Waste Generator Tons Generated Per Year '4 S+b S ❑Recycle f Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(221 7) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEG40UND 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 /> ❑ HotdWotel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housiag(2700)Use EmployeeHousine/La6or Camp Application Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPIISEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 P901 ❑ Spa 11 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# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets—Number ofUnits <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Lzadrill 11 Transfer Station ❑ Ag I Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste T-ire Facility ❑ Compost Facility 11Process/Recycle Facility ❑CIA Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑FarintRauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ SkilledNursing ❑Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10—❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use P1fSEADL6-02-003 BlueAppficarion Form <br /> EME GENCY NOTIFICATION FOR THIS PACILITY AND/OR PROGRAM <br /> CONTACT PERSON Y Day Pq o Night Ph <br /> PROGRAM ELEMENT FEE a? ❑ SurcL rge FE' ❑ Other FEE <br /> INSPECTOR# l�'2 PEAMIT VALID fl to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> El Cash REVIEWED By AccouNTRWOFFICE Date <br />