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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERMLE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit •IDS Pro ram Record ID -) S ' <br /> Facility Address 65 1 �i 1 <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 11 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 Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit–Make Vehicle Type Color <br /> Registration It License# Sticker# <br /> 11 Temporary Food Facility-----Dates of operation from to 11 lee Plant <br /> ❑ Special Event –Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Numbcr of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) /( n <br /> VIAZARDOUS WASTE PROGRAM(2200)y}� � V IUM ' C t <br /> 11 Hazardous Waste Generator–­L—Tons Generated Per Year - ❑Recycle I Exempt System(2299) <br /> U ❑ 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 U.ST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ IIotel/Mote1-----Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use F,mployee llousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAF Site ❑ Local HW Cleanup Site. L1NPL/SEP Cleanup Site ❑UIC Site <br /> 13Abandoned IIW Site 11 non-NPL/SEP Cleanup Site 11RWQCB Cleanup Site ❑ Nater 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 13ODY 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 of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash 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 /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited Ilauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2-10----❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIIS F,11D 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON ��)1 Day Ph Night Ph <br /> PROGRAM ELEMENT 1 e FEE11Surcha a Fee Otbgr-PEE <br /> INSPECTOR# �–b717 PERMIT VALID –7 to ❑ Food handler <br /> ❑ Check t AMOUNT PAIDI 7 Date INVOICE# <br /> El Cash REVIEWED BY �'1 1� O ACCOUNTING OFFICE Date ^� <br />