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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 0 New EH Program at Existing Facility []New EH Program and New Facility <br /> Facility ID � ��� � � Pro rantRecordID <br /> Facility Address -*fes <br /> (Please Check the appropriate description and specify ss number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating CapacitySquare Footage Food Handlers Course required:- Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number of Units - <br /> ❑Retail Markel—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 —Dated of operation from - to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑Grade B Dairy ❑Milk Dispeuser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) V <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle[Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 g) ❑ Silver Only(2222) _ ❑ Appliance Recyrlers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemtit-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 EmploreeffoasinKabor 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 MY Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site -❑Water Quality Remediatiou Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑P901 ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑Kenuel <br /> TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> PumperVehicle—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 Time Facility ❑ Compost Facility ❑ Process(Recycle Facility ❑ CIA Landrdl 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--O 2- 10—D 11-60---❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PNS EffD 46-02-003 Blue Application Form <br /> _EMERGENCY NOTIFICATION FOR THIS F=ACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph <br /> PROGRAM ELEN T -�=�J FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# QTY PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED'BY ACCOUNTING OFFICE Date <br /> ,� �„ Macterfle Record Pink <br />