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SAN JrOAQUIN COUNTY ENV RONMENTAL HEALTH DEPART TRENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EIi Program at—Existing Facility ew EH Program and New Facility <br /> Facilif 'h) �0 a'� Pro ram Record ID <br /> F acili(y Address <br /> (Please Check the appropriate description and specify s_ize,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> El Restaurant: Seating Capacity Square Footage Food handlers Course required:. YEs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only Elwith Food Preparation ❑Vendiag Machines—Number of Units <br /> ElRetail 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 Dispenser--Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS INVASTE PROGRAM(2200) a <br /> ❑ Hazardous Waste Generator"—Tons Generated Per Year ❑Recycle/Eaempf System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyders(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 /> ❑11otel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Ifousinzg4bor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAI'Site 11 Local IIW Cleanup Site. ❑ NPIJSEP Cleanup Site 11 UIC Site <br /> ❑Abandoned 11W Site ❑non-NPL/SEP Cleanup Site ❑RWQCB 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 /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4 121) ❑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/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIALandfrll Site <br /> e.fuse 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 ❑ Sldlled Nursing ❑Large Generator 0 Small Generator ❑ Limited Mauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60-----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePlf'SEHD 46-02-003 BhreApplicadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEME <br /> elNT 14 FEE 11 SurchargeFEE El Other FEE <br /> INSPECTOR# GSW o PERMITVALID to El Food Handler <br /> ❑ Check# CZ 1.12 AMOUNT PAID Date INVOICE# <br /> El Cash REVIEWEDBY SJLI�►3 ACCOUNTING OFFICE Date 71 3 <br /> Masterfile Record Pink <br />