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a AL <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVIS N <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit <br /> Facility ID ...00� —.Program Record ID <br /> Facility Address <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: Yrs❑ No ❑ <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# 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 /> HAZARDOUS WASTE PROGRAM(2200) - <br /> ❑ Hazardous Waste Generator-----------------------Tons Generated Per Year <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Pemut-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 /> ❑ Iiotcl/Motcl------Numbcr of Units - ❑ Jail or Exempt Institution--Number of Units <br /> Employee Housing(2700) Use Ernnlayee Housina/Ln6nr Caaru Anplicarion Form <br /> SITE MITIGATION(2900.9 -'$O UNDERGROUND INJECTION CONTROL(3000) <br /> N Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW 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 Battling Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ 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 ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>10 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility----El 2- 10-------011 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EM0069 Blue Application Forpt <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT --L91 .50 FEE ,o I ❑ Surcharge FEE ❑ Other FEE <br /> IINNspcCTOR''/# �_ Pctu IT VALID 2DO2��F4() to" El Food Handl�wer <br /> , lCheck#5kY5r 12o? AMOUNT PAID LDO'r(7f1 Date Il DINVOICE# d <br /> r I Cash -REVIEWED mY IJIJC [0i D ACCOUNTING OFFICE <br /> Date [f 7 <br /> EH 0:69 PINK FORM.doc _ oma„ mrrnrno <br />