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SAN JOAQUIN COUNTY EN ONMENTAL HEALTH DEPART T <br /> MASTERFILE RECORD INFORMATION FORM <br /> Ne�v EH Program at Existing Facility ❑New EH Program and NewFacilityFFa' <br /> Facility ID F�� cilit <br /> G U I '� �� Program Record =P-V ,55L(ID F S <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> S Footage Food Handlers Course required: YES ❑ No ❑ <br /> 11 Restaurant:Restaurant: Seating Capacity q g <br /> ❑ Commissary El Dry storage only El with Food Preparation ❑Vending Machines--Number of Units <br /> 11 Retail Market----Square footage ❑ with Meat Market only [I Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> El Mobile Food Vehicle-----Make Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> 11 Mobile Food Prep Unit -`lake Sticker# <br /> Registration# License# <br /> ❑ <br /> to Ice Plant <br /> 13 Temporary Food Facility-----Dates of operation from ❑ Produce Stand <br /> ❑ Special Event --Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> ❑ Milk Dispenser --Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy El Grade B Dairy <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM (2200) ❑ Recycle/Exempt System (2299) <br /> ❑ Hazardous Waste Generator------------Tons Generated Per Year ❑ Appliance Recyclers (2217) <br /> El CRT Offsite Handlers (2218) El Silver Only (2222) PP <br /> Tiered Permitting Facility------------------❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> El 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(arms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution-2222--Number of Units <br /> [3 Hotel/Motel-2222--Number of Units <br /> m�Application Form <br /> Ilousinl;(2700) Use Employee E/ousing/!nhur Cm <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> SITE MITIGATION(2900) <br /> e ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> El Environmental Assessment ❑ UST-CAP Site El Local HW Cleanup Sit <br /> ❑ Abandoned IIW Site <br /> ❑ 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) ❑ Kennel <br /> ❑ Poultry Farm -------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(-4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) Capacity Vehicle# <br /> [I Pumper Vehicle -Registration# License# p Y <br /> Chemical Toilets ------Number of Units <br /> ❑ Pumper Yard ❑ Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ A /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Landfill ❑ 'Transfer Station g ElrocesEl CIA Landfill Site <br /> Ps/Recycle Facility <br /> 9 Waste"fire Facility El Compost Facility ElFarm/Ranch Clcanup Site <br /> ❑ Refuse Vehicles--Number of Units _ E] Ihimpslcrs>20 cu yd Numbcr of Uni[s <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator F-1 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----❑ 2- 10------- ❑ It -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PliVS EHD 46-02-003 BlaeApplication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACTPERSON <br /> i( ❑ Surcharge FEE ElOther FEE <br /> PKOGR:\�I ELEMENTi U FEE ❑ Food Handler. <br /> INsrecrolt# (;{��� O <br /> PERMIT VALID t0 <br /> Date INVOICE# <br /> [I Check re AMOUNT PAID l � / <br /> ^ ACCOUNTING OFFICE Date h <br /> 11 Cash REVIEWED BY`� t� <br /> Masterfile Record Pink <br /> 48-02-014 <br />