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SAN JOAQUIN COUNT�NVIRONMENTAL HEALTH DIVA-ON <br /> MASTERFILE RE D INFORMATION FORM(EH 00 69 <br /> ew EH Program at Existing Facility ❑New EH Pro ram and New Facility <br /> Facilit i ID Pro 9ram Record ID <br /> Facility Address — <br /> (Please Check the appropriate description and specify size,number of y4its and pertinent inform tion.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity - Square Footage Food Handlers Course required: YES❑ 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 Vchicle Type _ Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type -' Color <br /> Registration# License# Sticker# <br /> 11 -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 Dispenser---Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle I Exempt System <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Perrtdt-By-Rule Fixed Unit ❑ Pemtit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)----Number ofAST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and 6 fonus <br /> HOUSING PROGRAM(2400) - <br /> ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700) Use Employee Housing/Labor Comp Annlicarion Form <br /> SRCREA:l <br /> ITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> romentalAssessmentUST-CAPSite ❑ Local IW Ieanup Site ❑ NPWSEP Cleanup Site ❑ UICSiIc <br /> nded HW S -NPL/SEPCleanup SitcId RWQCB Cleanup Site ❑ Water Quality Remediation Sitc <br /> ONAL HEALTH PROGRAM(3600) LL 3 <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, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ 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) 4 <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/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 13 2- 10-------❑ 11 -60-----❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS E110069 blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# J PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> Ell 0069 Pink Fops Rev.02/25/03 <br />