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SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility New EH Program and New Facility <br /> Facility ID ®�, ) Pro ram Record D <br /> Facility Address i �3tAt <br /> (Please Check the appropriate description and specify size.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 Elwith Food Preparation ❑Fending 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 /> 11Temporary Food Facility—Dates of operation from to El lee Plant <br /> [l Special Event --Dates of operation from to El Produce Stand <br /> DAIRY PROGRAM(20W) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> GUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑Hazardous Waste Generator..= —Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) Cl Silver Only(2222) _ ❑ Appliance Recyclers(2217) <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 /> ❑ IIotet/Motei Number of Units ❑Jail or Exempt Institution Number of Units <br /> Eaaptoyee housing(2700)Use Employee Housia ffAgbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑Local IBV Cleanup Si.te• ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned IIW Site ❑ non-NrIJSEP Cleanup Site ❑RWQCB Cleanup Site '❑Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility. ❑P901 11 spa ❑Out of Service PooUSpa 11 Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds 1:1 Kennel <br /> TATTOO 13ODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> [I pamper 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 ❑ Studge/Ash 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/Finch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ SI lled'Nursing Large Generator ❑ SmaIl Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility--O 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UsePFVSLHD 46-02-003 -BlueAppticarion Form <br /> EMERGENCY NOTIFICATION FORTHiS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph _ <br /> PROGRAM ELEMIENT� ]�-IFEE 11 SurchargeFEE ❑ Other FEE <br /> INSPECTOR# ---,off-- PERMITVALID to 11 ❑ Food Handier_ <br /> CJ Check f Axou P a.tu 1 I,L C;;"� _ Date INVOICE# � ✓ . <br /> Cash 2 EVIE�'1EU II� 1 ACCOUNTING It bate -- )___.�_�� <br />