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o <br /> SAN J AAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New Ell Program al Existia Facility ❑New EH Program and New Facility <br /> Facilif `ID f-/� �- Pro ram Record ID i`7 35 <br /> facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Seating Capacity Square Footage Food Handlers Course required: 1'Es El 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# License# Sticker# <br /> [] Temporary Food Facility—Dates of operation from to Ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(200 ) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ h1ilk Dispenser—Number of Containers in Multi-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2216) ❑ 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 UST A and B Forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Ilotentotel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee Ifousiag(2700)Use Fmployec Horrsinc/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13Environmental Assessment ❑ UST-CAP Site ElLocal IIW Cleanup Site. El NPL(SEP Cleanup Site El UIC site. <br /> ❑ Abandoned I1W Site ❑ non-NPI./SEP Cleanup Site ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility 11 Pool 11 spa El Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11 Poultry Farm Maximum number of birds Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> [I Landfill El 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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care L1 Skilled Nursing 1:1 Large Generator 11 Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility----El 2- 10 ❑ 11-60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS F11D46-01-003 BlueApplica(ion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> 1 <br /> J ' � i <br /> PROGRAM ELFNIENT 4 7 Z7© FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# !�[fj� PERN11TVALID to ❑ Food Handler__ <br /> ❑ Clreck# AMOUNT PA L) hate INVOICE# <br /> max— <br /> El Cash P`EViEWEDB1' ACCOUNTING OFFICE _ _ nate FJ <br /> – –. _-_ <br />