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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ew EH Pro am at Existing Facility ❑New EH Program and New Facility <br />Facility ID �l-1 Program Record ID P9 05--70 <br />Facility Address <br />(Please Check the appropriate description and specify E!Z number of units and pertinent information) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes ❑ 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 <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # Licerm # <br />❑ Temporary Food Facility ---Dates of operation from = to <br />❑ Special Event —Dates of operation from to <br />Color <br />Sticker # <br />Color <br />Ct;A —r if <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200) t <br />Hazardous Waste Generator. Tons Generated Per Year C+� . ❑ Recycle f Exempt S} stem (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (7222) _ ❑ Appliance Recyclers (2217) <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fired 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 />❑ IIotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Funplaree Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />11 Environmental Assessment 13 UST -CAP Site ❑ Local IIW Cleanup Site. 13NPLISEP Cleanup Site 11 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 . ❑ P901 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds _ <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (4121) ❑ Body Piercing (4120) <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # _ <br />❑ Pumper Yard <br />❑ Kennel <br />❑ Permanent Cosmetics (4122) <br />License # Capacity Vehicle# <br />❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site ❑ Sludge/Ask Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA -Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsfers > 20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator D Small Generator ❑ Limited Iiauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -0 2 - 10 ❑ 11- 60 -----❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pif'SEKDJ6-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGItA>•Z ELE ZENT �2'� FEE 2 y ❑ Surcharge FEE <br />INSPECTOR# Zb�'�) PERMIT VALID $ LT -1 to (� 3 I I U <br />❑ Check # AIIZOUNT PAID Date 5 23 <br />❑ Cash REVIEWED BY <br />❑ Other FEE <br />❑ Food Handler / " <br />INVOICE # ' � 2-0 L/ � <br />ACCOUNTING OFFICE L45 Date <br />3 L <br />