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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART117CNt' <br /> MASTERFILE RECORD INFOR117ATION FORIA <br /> 19-New EH Program at Existin Facility []New Ell Program and Nese Facility— <br /> Facility <br /> acilityFacilit y ID `� Pro ram Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent info mation.) <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 h1achioes—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 Eveut —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ llfillt Dispenser--Number of Containers in Mufti-Ilead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) I <br /> ❑ Hazardous Waste Generat`Ior- Tons Generated Per Year ❑ Recycle I 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 /> ❑Pcrrnit-By-Rule Fixed Unit ❑ Pcmut-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(arms <br /> 14OUSING PROGRAM(2400) <br /> ❑ IIotel/141ote1 Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fnrplopee Ifousinr/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmeatal Assessment ❑ UST-CAP Site ❑ Local IIW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned I11V Site ❑ non-NPLJSEP 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 Sen-ice 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(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 ❑ Transfer Station 1:1 Ag/Cannery Waste Site El Sludge/Ash Site <br /> 0-Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA,Landfill Site <br /> ❑ Refuse Vehicles-Number of Units ❑ Dumpsters>20 cu.yd--Number of Units ❑ FarrmTanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> El Primary Care 11 Acute Care El Skilled Nursing 1:1 Large Generator 11 Small Generator [1 Limited IIauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---El 2-10 ❑ 11 -60--❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use Plf SFIID 46-02-003 Blrre Application Form <br /> EMERGENCY NOTIFICATION FORTHIs FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> 11Rocam t ELERIENT—1-L-O - FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PEKNUT VALID to ❑ Food Handler <br /> ❑ Check 9 AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWE=D BY ACCOUNTING OFFICE Date <br />