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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDIVISION <br /> MASTERFIL.E RECORD LNFORVLaTION FO S(EH 00 69) <br /> New EH Pro and�Iew Facility <br /> ❑ New EH Pro at Existing Facility_ <br /> Facili ID (�� v to i— Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course req— uired: YEs ❑ No ❑ <br /> ❑ Restaurant: Seating Capacity - Square Footage <br /> ❑ Commissary ❑ Dry storage only <br /> ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> C1 Retail Market--Square footage <br /> C3 with Meat Market only C3 Multiple Departments C1 Prepackaged Goods Only <br /> Color <br /> e <br /> Vhicle Type Bricker <br /> ❑ Mobile Food Vehicle--Make License R <br /> Registration# Color <br /> Vehicle Type Sticker",C3Mobile Food Prep Unit--Make License# ❑ Ice Plant <br /> Registration R to <br /> ❑ Temporary Food Facility--Dates of operation from ❑to Produce Stand <br /> ❑ Special Event - Dates of operation from <br /> DAIRY PROGRAM (2000) <br /> C1Grade B Dairy C1 Milk Dispenser—Number of Containers in Multi-Head Utnt <br /> ❑ Grade A Dairy <br /> CUP A ❑ State Facility Surcharge(2399) <br /> I-LAZARDOUS WASTE PROGRAM(2200) —Tons Generated Per Year <br /> ❑ Hazardous Waste Generator-------------- ❑ Conditionally Exempt( <br /> (CE) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) C] permit-By-RuleHousehold Hazardous Waste <br /> ❑Permit-By-Rule Fixed Unit <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) ❑ Jail or Exempt Institution Number of Units <br /> ❑ HotellMotel-------Number of Units licatian Form <br /> Employee Housing(2 100) Use Emplo ee Noie,i L�lLahor Camp App <br /> SITE MITIGATION(0) Us UNDERGROUND INJECTION CONTROL(3000) ❑ UIC Site <br /> ❑ NPL/SEP Cleanup Site <br /> Water Quality Remediation Site <br /> ❑ Environmental Assessment ❑ UST-CAP Site C3 Local HW Cleanup Site <br /> ❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ <br /> RECREATIONAL HEALTH PROGRAM(3600) ❑ Natural Bathing Area <br /> Number of PooWSpas at Facility <br /> C3 Pool ❑ Spa ❑ Out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) El Kennel . <br /> ❑ Poultry Farm ' Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) C1 Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle#�� <br /> # <br /> C1Pumper Vehicle—Registration# o ❑ Chemical Toilets Number of Units <br /> F1 Pumper Yard C3 Package Treatment Plant <br /> SOLID WASTE PROGRAM(4400) , g Waste Site [I Sludge/Ash Site <br /> C1 Landfill ❑Transfer Station <br /> ❑ �, /Cannery [I CIA LandPdl Site <br /> C3 Waste Tire Facility ❑ Compost Facility <br /> [IProcess/Recycle Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles—Number of Units� ❑ Dumpsters>'70 cu yd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Skilled Nursing ❑ - 10 ❑ I l -60--❑>60 generators <br /> ❑ Primary Care ❑ Acute Care ❑ Common Storage Facility — <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> Form <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use pWS n <br /> NOTIFICATION FORTHIS FACILITY AND/OR PROGRAM <br /> EMERGENCYNight Ph <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> �� ❑Surcharge FEE <br /> PROGRAM ELEMENT as FEE to ❑ Food Handler <br /> INSPECTOR# DJg PERMIT VALID INVOICE# ' <br /> Date <br /> ❑ Check iF LIMOINT PAID Date b � <br /> ❑ Cash REVMvED BY <br /> AcCoUNruaG OFFICE may,07/071,99 <br />