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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD"INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility IDQ Program Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify jjM number of units and pertine_nt information) - <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YES❑ Na❑ <br /> ❑ Commissary ❑ Dry storage 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# $ticker# <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 /> 11 Special Event --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Drury ❑Grade B Dairy ❑Milk Dispenser—Number of Containers in Multi-Head Unit <br /> �.-CUBA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 9 <br /> ❑hazardous Waste Generator. Tons Generated Per Year ❑Recycle 1 Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Faca'lity ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-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 USTA and B forays <br /> HOUSING PROGRAM(2400) <br /> ❑HotwMotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Em le ee Aeasin /Labor Cam Applicadort Foray <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> © Environmental Assessment ❑UST-CAP Site ❑Local L W Cleanup Site. ❑NPLISEP Cleanup Site ©UIC Site <br /> ❑Abandoned IiW Site ❑non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site ❑Water Quality Remediation Site.' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility. ❑Pool ❑Spa ❑Out of Service Poo!/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) Li ��J� � acity <br /> J�umper Vehicle Registration# Vehicle t€ <br /> ❑Pumper Yard El Package Treatment Plant- ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑Landfill ❑Transfer Station ❑Ag 1 Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcesslRecycle 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 ❑ Sldiled'Nursing ❑Large Generator ❑ Small Generator ❑Limited hauler <br /> 13 Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—[] 2-10 ❑ 11-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EMD 46-02403 Blue Apr4cation Form <br /> �12MFRGENCY 1'I0TzrICATiON FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON �!✓/�7 Day P /Flight Ph <br /> PROGRAM ELENIENr'T FEE "9 1 S ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMITVALID to 3 a ❑Food Handler <br /> ❑ Check# AMOUNT PAID _ Lt,r ]b Date INVOKE# l 7 q--7 <br /> El Cash REViEWEIiBY ACCOUIrYING OFFICE Date <br />