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SAN JOAQUIN COUNTY ENVIRONMENTAL REALTI1 DEPARTMENT <br /> MASTERFILE RECORD 3NFORMAT ION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID r Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify EiLe,number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ <br /> ❑Commissary ❑ Dry storage only ❑with Food Preparation ❑Pending 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(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenscr Number of Containers in Multi-Head Unit <br /> COPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 1 <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑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 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 Empleyee Oousinz/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 ❑RNVQCB 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 /> yECTOR.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 of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag/CanneryWaste 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 /> ❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑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 PN'SEHD 46-02-003 BlueApplica6an Form <br /> EMERGENCY NOTIFICATION FOR TH15 FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT Lf� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# eo� PERMIT VALID to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REvIEWEDBY K )4Z-Yoj7ACCOUNTING OFFICE Date <br />