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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> J New EH Program at Existin Facility WNew Eli Program and New Facility <br /> Facility ID Pro ram 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 IIandlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation El Vending Machiues—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Markel only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Tlobile Food Vchicle---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 ❑ IlIilk Dispenser---Number of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAh1(2200) a <br /> ❑ Hazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Rccyclers(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) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use USTA and B(onus <br /> HOUSING PROGRAM(2400) <br /> ❑ IloteVNIotel Number of Units ❑ Jail or Exempt Institution--Number of Units <br /> Employee Itousiug(2700) Use Employee Ifousin�,II,abor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned IIW Site ❑ non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site ❑ Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑Out of Service PoolfSpa ❑ 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(4121) ❑ 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 ❑ Sludr/Ash Site <br /> ( 1 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> b Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑ Veterivary Clinic ❑ Common Storage Facility---E] 2-10 ❑ 11 -60---❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PIIS EHD 46-42-003 Blue Application FOnn <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT �L FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# .11t PERMIT VALID to ❑ Food handler <br /> ❑ Check Y AmOUNT PAID Date INVOICE It <br /> ❑ Cash REVIEWED BY M5 t'� ACCOUNTING OFFICE 1 Date <br />