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SAN JOAQUIN COUNTY E ',,f <br /> RONMENTAL HEALTH DEPARTIGIENT <br /> MASTERFH.E RECORD INFORMATION FORM <br /> ew EH Pro m at Existin Facili QD u l c)S ❑New EH Pro am and New Facility <br /> [FacilityED AA- Doo (o'[ q C7 Proaram Record ID p Sg:�to <br /> Facility Address 13 13 <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: . .. Seating Capacity . _Square Footage _....__. ---,-Food Handlers Course required:--YEs❑ -Na o - <br /> ❑ Commissary ❑ Drystorage 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 <br /> 11 Plant <br /> 11Special Event --Dates of operation from to IJ Produce Plant <br /> DAIRY PROGRAM(2000) <br /> tand <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA ❑ State FacilitySurcharge(2399) - <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator--- --Tons Generated Per Year O Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> iered Permitting Facility ❑ Conditionally Authorized(CA) Conditionally Exempt(CE) <br /> emelt-By-Rule Fixed Unit ❑Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACIL Y(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B farms <br /> HOUSING PROGRAM(2400) - <br /> ❑ HoteU141otel----Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Honsine/Labor Camp Application Form <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 HW 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 <br /> ❑ 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 11Chemical 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/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler - <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--0 2- 10-----❑ 11 -60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-01-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE 7/,S ❑Surcharge FEE ❑Other FEE <br /> INSPECTOR# PERMIT VALID / �Oq��� to Wit/D 9, 13 Food Handler <br /> 131 <br /> Check# - AMOUNT PAID ® Date 1 D 3 0 INVOICE# l Q.,3 / <br /> 13 cub REVIEWED BY 1 a ACCOUNTING OFFICE Date (D 1 p <br /> 4&02-034 Muterfile Record Pink <br /> 10(612003 <br />