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SAN JOAQUIN COU ENVIRONMENTAL HEALTH ION <br /> v MASTERFIL INFORMATION FORM <br /> ❑New EH Program at Existing Facili ew EH Pro am and New FacilityPA's( k <br /> Facility ID Obl 6 Pro ram Record.ID ECE VET <br /> D 3 R <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) t4 usiy <br /> EJOP1 NIM NTP11- <br /> FOOD PROGRAM(1600) 5-PIN �EgNTA <br /> MEKT <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course re u 'fH"Ft No❑ <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# 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 --Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser---Number of Containers in Multi-Head Unit <br /> COPA, ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----------Tons Generated Per Year ❑ Recycle/Exempt System <br /> Tiered Permitting Facility ❑ 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 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 Employee Housing-/Labor Camp Application Form <br /> n <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000)' <br /> 11 Environmental Assessment 11UST-CAPSite ❑ 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 ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--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 `N 5 ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility VL ❑ CIA Landfill Site <br /> Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number of Units1 ❑ Farm/Ranch Cleanup Site <br /> w <br /> MEDICAL WASTE PROGRAM(4500) 2'� y�`-Z— 06YI—L <br /> ❑ Primary Care E3 Acute Care ❑ Skilled Nursing ❑ Lafge-G—e�+ne—rat—or ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-----❑ 2- 10-------❑ 11 -60------❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON II Da Ph Night Ph <br /> PROGRAM ELEMENT FEE %fl 11015 Surcharge FEE ❑ Other FEE <br /> INSPECTOR# ff-OyS PERMIT VALID 1/1'C) to 1-13D(Dq E] Food Handler <br /> Check# Q L S AMOUNT PAID �[ .DID Date 1 D o 'VOICE# l S 3 13 _ <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> EH 0069 Pink Form 'To -rDtj I)5 F'0 Lt I /3t(V ) <br /> / Rev.02/25/03 <br />