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SAN JOAQUIN COUNTY EONMENTAL HEALTH DEPARTWT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility tiew EH Program and New Facility <br /> Facility ID Program Record ID S� <br /> Facility Address iit)" X <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No 11 <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 a Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License= Sticker# <br /> El Temporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> El Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM (2000) <br /> 11 Grade A Dairy El Grade B Dairy 1:1 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/Exempt System (2299) <br /> ❑ CRT Offsite Handlers (2218) ❑ Silver Only(2222) ❑ Appliance Recyclers (2217) <br /> Tiered Permitting Facility------------------11 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 CSTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Nlotel-------Number of Units ❑ Jail or Exempt Institution-------Number of Units <br /> Employee(lousing(2700) Use Employee Flousing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local FIR'Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ R«QCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility El Pool 11 Spa El 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(4 100) <br /> 1:1 Tattooing(412 1) 1:1 Body Piercing(4120) El Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> 11 Pumper Vehicle -Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill ❑ Transfer Station El Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> Q.Jvastc'hire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br /> ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units __ ❑ I)umpsters>20 cu yd----Number of Units ❑ Farre/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing 11 Large Generator ❑Small Generator El Limited Hauler <br /> El Transfer Station El Veterinary Clinic ❑ Common Storage Facility----El 2- 10--- ❑ 11 60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> C {�I liM('I'VnLtn to El Food Handler <br /> INsrEcrol;# UtJUl <br /> ❑ Check it AMOUNT PAID Date ° INVOICE# <br /> ❑ Cash REVIEWEDBY }y (t �, <br /> ACCOUNTING OFFICE Date l "1 <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 <br />