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SAN JOAQUIN COUNTY LNVIRONAI,ENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMA'T`ION FORM <br /> ❑New EH Program at ExistingFacility ew EH Program and New facility <br /> Facilif ID Pro raraRecordl It <br /> Facility Address <br /> (Please Check the appropriate description and specify size'number oC units and pertinent inCormatio¢.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YEs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number ofUnits <br /> ElRetait Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> F1e MobilFood 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 /> 11Special 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-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑hazardous Waste Generator..— Tons Generated Per Year ElRecycle/Eacrarpf System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exc-mpt(CE) <br /> ❑Pemait-lay-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 /> ❑ Ilotel/11Iote1 Number of Units ❑Jail or Exempt Institution Number of Units <br /> E'niploym Ifousing(2700)Use Employee HorrsinzlEabor Camp Application Form <br /> SITE MITIGATION(2940) UNDERGROUND INJECTION CONTROL(3000) <br /> 11Environmental Assessment ❑UST-CAP Site ®Local MV Cleanup Site. ❑NPIJSEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned 1BY Site ❑ nou-NPLISEP Cleanup Site ❑R�VQCB 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 ®Itiennel <br /> TATTOO,13ODY 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 ft <br /> Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill E] Transfer Station 11 Ag/Cannery Waste Site 11 Sludge/Ash Site <br /> SVaste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <br /> El efuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm[Ranch Cleanup Site <br /> MEDICAL.WASTE PROGRAM(4500) <br /> El Primary Care El Acute Care ❑ Skilled Nursing F1 Large Generator El Small Generator El Linuted Ila-tiler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑ >60 generators <br /> PUBLIC WATER SYS'T'EM PROGRAM(4600)Use PIVSF TD 46-02-003 Filrce.Applica[ion Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY AND/OTR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> _ IEE ❑ Surcharge FEE ❑ Other FEE <br /> PROGRAM ELEMENT LA — <br /> INSPECTOR# S ()h PER1�T1T VALt —__ to ❑ Food Handler _ <br /> El C heck f` A_ IOUN'r l'.ry.Y J _ Date It VOICE€€ <br /> ❑ Cash RE%'1E%VFD BY ACCOUNTIi.G OFFICE <br /> — — - --- <br />