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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New Ell Program at Existing Facility f New EH Pro gram and New Facility Facilit •ID D O Program Record ID Facility Address (Please Check the appropriate description and specify size'number of units and pertinent information.) FOOD PROGRAM(160x?) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units El Retail Market----Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker# ❑Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility-----Dates of operation from to ❑ Ice Plant [3 Special Event —Dates of operation from to ❑ Produce Stand DAIRY PROGRAM(2000) ry ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi-Head Unit CU PA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) ❑ hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) ❑ CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste ❑ ABoVEG40UND STORAGE TANK FACILITY(AST)(2390) Number of AST UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms tjOUSING PROGRAM(2400) ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units Employee Housing(2700)Use Employee 7fousing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site ❑ Abandoned IHV Site 13non-NPLJSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of rools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4 120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill 11 Transfer Station 13 Ag/Cannery Waste Site ❑ Sludge/Ash Site 9 Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--0 2-10 ❑ 11-60------❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) UscPFF'SGHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM CONTACT PERSONA �r 1.I,J Day Ph Night Ph PROGItAi`i ELEM'E`NT/ 1 V FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# I J�I�i ID PERMIT VALID to ❑Food Handler ❑ Check P AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY -t ACCOUNTING OFFICE Date