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S <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORDINFORMATION FORM <br /> New EH Program at Existing Facility ❑Ne\v Eli Program and New Facility <br /> Facilit•iD Pro ram.Record lD <br /> Facility Address i oL <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Cl Restaurant: Seating CapacitySquare Footage Food handlersCourse required:. Yes❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Fending Machtues—Number of Units <br /> ❑Retail Alarket—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> 11Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration it 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 /> v CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) f <br /> ❑hazardous Waste Generator..= Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-lay 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 .❑Tail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Ifousine/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Em4roumental Assessment ❑UST-CAP Site 11Local MV Cleanup Site, 11NPLiSEP Cleanup Site ❑UIC Site <br /> L1 Abandoned IINV Site ❑nou-NPIJSEP Cleanup Site ❑RNVQCB Cleanup Site ❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3604) <br /> Number of Pools/Spas at Facility. ❑Pool ❑ Spa ❑Out of Service Poolfspa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> 11Poultry Farm Maximum number of birds 11 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• ❑Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill 11 Transfer Station 11 Ag/Cannery Waste Site 11 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 ElAcute Care ❑Skilled Nursing ElLarge Generator ElSmall Generator ❑Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--E] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePIPSEWD M-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION Folz Ttits FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAMELEMMT'_ jL� FEE ❑ Surcharge Fee - ❑ Other FEE — <br /> INSPECTOR#_ jPEFMIT VAL'eD ,L to �L 1 jli ❑ Food FIandler! <br /> 11 Check k AMOUNT P AAD l 1� _ Date 1P7V010E# �l�'_ _-- <br /> Cash REVIEWED BY COUNTII11, FILE <br />