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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ❑New EH Program at ExistingFacility ❑New EH/P�rog�r M and New <br /> Facility <br /> Facility ID f4 C D,1 �- + Pro ram Record ID '`-iJ S✓ r ( 0 <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of units and pertineat information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Ym❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only 11with 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 11Produce Stand <br /> DAIRY PROGRAM(20W) <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) 4 <br /> ❑ Hazardous Waste Generator.— Tons Generated Per Year ❑Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ 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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use F,ployee Housing/Labor Camp Application Forst <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site, ❑ NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IiW Site ❑non-NPLISEP 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 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# <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>20 cu.yd—Number of Units ❑ Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑Large Generator E7 Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--[] 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Plf'SEHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR Ttits FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph _ <br /> PROGRAM ELEMENT 914iU FEE ❑ Surcharge FEE ❑ Other FEE <br /> INsrECroRtE PERMITVALIDto ❑ Food Handler <br /> 0 C:hcck tr_ /mouN'T PAID _ _ _ Date_ INVOICE i#? _ <br /> 0 Cashv�. v1 _ 1QE.VIFW;iuKN — P.CCCt1NI:N(i OFFICE ��__ _ %Date 3 __---- <br />