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SAN JOAQUIN COUNTY t, tRONMENTAL HEALTH DEPAR NT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> t Facility ID f L_ �r rzy Program RecordID �i f <br /> Facility Address <br /> (Please check the appropriate description and specify side number Of units an,pertinent information.; <br /> FOOD PRQCRAM(1600) <br /> 0 Restaurant: Seating Capacity__ __ Square Footage Food Handlers Course required: YEs O No O <br /> O Commissary O Dry storage only ❑ with Fond Preparabun OVending Machines Number of Units <br /> '© Retail Market—Square footage__ O with Meat Market only O Multiple DepartmentsO Prepackaged,Goods Only <br /> O Mobile Food Vehicle--Make Vehicle Type Color__��_ <br /> Registration I; License m _LL _ Sticker#_ <br /> ,I O Mobile Food Prep Unit Make _ Vehicle Type <br /> Registration ii' _i License#— Sticker n_ <br /> O Temporary Food Facility—Dates of operation from to O ice Plant <br /> O Special Event Dates of operation from to O Produce Stand <br /> OOA RY PSgGRAM (2006) <br /> p: O Grade A Dairy Q Grade B Dairy O Milk Dispenser-Number of Container in Multi-Head Unit.----_, <br /> U A ❑State.Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> O Hazardous Waste Generator----------.Tons Generated Per Year O RecychilExempt System(2299} <br /> 0 CRT Offsite Handlers(2218) --------- ❑ Silver Only(2222) O App;iance Recyclers(2217) <br /> Tiered Permitting Facility---------- — O Conditionally Authorized(CA) O Conditionally empt{CE) <br /> e, ,. O Permit-By-Rule Fixed Unit O Permit Bello, -tousehold Hazardous a'sfe <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> (UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms, <br /> HQUSING PROGRAM(2400) <br /> O HoteliMotel—Number of Units O Jad or Exempt institution",-'4mber <br /> Employee Housing(2700)Use Employee HousingpLabor Camp App(cation Form <br /> SlTBMiTIGATION(2900) UNDERGROUND lNJEO`f?ON CONTROL(3000) <br /> 0 Environmental Assessment O UST-CAP Site 0 Local HW Cleanup Site O NPLJSEP Cleanup Site 0 UIC Site <br /> O Abandoned HW Site O non-NPLISEP Cleanup Site O RWQCB Cleanup Site O Water Quality Remediation Site <br /> t. RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolsiSpas at Facility____ O Pool O spa O Out of Service Poolispa O Natural Bathing Area <br /> . VECTOR CONTROL PROGRAM(4000) <br /> O Poultry Farm--,Maximum number of birds , O Kennel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(41.00) <br /> O Tattooing(4121) 171 Body Piercing(4120) O Permanent Cosmetics(4'4 <br /> LIQUID WASTE PROGRAM{0200•) <br /> O Pumper VehiclaRegistration ri _ License#_ Capacity___ Vehicle# <br /> 0 Pumper Yard O Package Treatment Plant O Chemical Toilets—Number of Units _ <br /> SOLID WASTE PROGRAM(4400) — <br /> O Landfill ❑ Transfer Station O AgiCannery Waste Site O Sludge,/Ash Site <br /> O Waste Tire Facility O Compost Facility O Process/Recycle Facility O CIA Landfill Site <br /> O Refuse Vehicles t»e(U=) O Dumpsters>20 cu yd{.ofunitc 0 FarrnlRanch Cleanup S f <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑Primary Care O Acute Care O Skilled:Nursing O Large Generator O Small Generator O Limited Hauler <br /> O Transfer Station O Veterinary Clinic O Common Storage Facility O 2- 10 O 11 60 O >60 generators:.. <br /> PU60C WATER SYSTEM PROGRAM(4600)Use PWS EHID 46dt2-03 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON flay Ph,,.,__ Night PTI <br /> PROGRAM ELEMENT «' � l FEE O Surcharge FEE O Other FEE_ <br /> INSPECTOR$ rtTI�f PERMIT VALID — to __ O Food Handier <br /> - ❑ Check# AMOUNT PAD . .Date INVOICE.# <br /> ❑ Cash REVIEWEDBY AccouNTING OFFxcy a Date <br /> < 'I RDvdAS ER71RENL4i 'i*.K.'( <br /> rs .,P .w.r.... <br />