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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL I3EALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit y ID ,::A e o 1`. _,7 t^e Pro ram Record ID <br /> I+acility Address T t 4 r 1a� R�� ; L�����► <.;� <br /> (Please Check the appropriate description and specify s_ize,number of units and pertinent information.) <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 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 /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑ hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(22 is) ❑Silver Only(2222) _ ❑ Appliance Recyclers(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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotc"lotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ilousin,p/I,abor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local RW Cleanup Site. ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned I1W 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(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 /> ❑JGandfill ❑Transfer Station 13 AC/Cannery Waste Site ❑ Sludge/Ash Site <br /> Waste Tire Facility 11Compost Facility 11Process/Recycle Facility 11 CIA Landfill Site <br /> ❑ Refuse 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 ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited IIauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility----❑ 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PHS FHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> I'ROGRAbt ELEMENT L 7 110 FEE 11 Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID . to ❑ Food handler <br /> ❑ Check# A11'IOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date C tyS <br />