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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Record ID Facility Address (Please Check the appropriate description and specify size, number of units and pertinent information) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines Number of Units ❑ Retail Market ---Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit—Make Vehicle Type Registration # License # ❑ Temporary Food Facility -----Dates of operation from to ❑ Special Event —Dates of operation from to _ Color Sticker #_ _ Color Sticker # ❑ Ice Plant ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -Head Unit CUPA ❑ State Facility Surcharge (2399) HAZARDOUS WASTE PROGRAM (2200) i ❑ Hazardous Waste Generator. Tons Generated Per Year [I Recycle f Exempt System (2299) ❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2217) Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) ❑ Permit -By -Rule Fixed Unit ❑ Permit -By -Rule Household Hazardous Waste b ABOVEGROUND STORAGE TANK FACILITY (AST) (2390) Number of AST z 3UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms OZ v oZ HOUSING PROGRAM (2400) ❑ Hotcl/Motel Number of Units .❑ Jail or Exempt Institution Number of Units Employee Housing (2700) Use Employee lfeusingTabor Camp App(icadon Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR.CONTROL PROGRAM (4000) ❑ Poultry Farm Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) ❑ Tattooing (4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) LIQUID WASTE PROGRAM (4200) 0 Pumper Vehicle Registration # License # Capacity Vehicle# ❑ Pumper Yard . ❑ Package Treatment Plant- ❑ ChemicaI Toilets Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA.Landfill Site ❑ Refuse Vehicles --Number of Units ❑ Dumpsters > 20 cu yd Number of Units ❑ Farm/Rauch Cleanup Site MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator Small Generator 11 Limited hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---[] 2 -10 ❑ 11- 60 ----❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PFVSEHD 46-02-003 BlueApplicalion Form EMERGENCY NOTIFICATION FOR wis FACILITY ANDIOR PROGRAM Day Ph Night Ph CONTACT PERSON PROGRAM ELEMENTo�_ FEE ❑Surcharge FEE ❑Other FEE INSPECTOR# LP 1 PERMIT VALID to ❑ Food Handler ❑ Check # AMOUNT PAID Date 0 OQINVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE — 1v Date , 1 )/V a _