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t <br /> SAN JOAQL;IN COUNTY ENrVIRONMEN'TAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> D!kNew EH Program at ExistinggFacility []New EH Program and New Facility <br /> Facilit I➢ ���, l V Pro am Record ID O 5-3 <br /> Facility Address ' o <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 El <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending Machines—Number ofUnits <br /> ❑ Retail Mark=et—Square footage ❑with Meat Market only ❑MuItiple Departments ❑ Prepackaged Goods Only <br /> 11Mobile 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 /> CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) l <br /> ❑Hazardous Waste Generator..- Tons Generated Per Year ❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(221 S) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) Cl 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 /> ❑ Hotenlotel Number of Units I]Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmploree7-fousia.Zagbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(30W) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local IIW Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned HAY Site ❑non-NPIJSEP 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 /> CI Poultry Farm Maximum number of birds 11 Kennel <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(4121) Cl 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 I Cannery Waste Site ❑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/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) / <br /> ❑ Primary Care ❑Acute Care �C�j Skilled Nursing 11 Large Generator 0 Small Generator ❑Limited Iiauler <br /> 1:1 Transfer Station 11 Veterinary Clinic ` ❑ Common Storage Facility--D 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIVS EHD46-02-003 Blrre Applica(ian Form <br /> EMERGENCY NOTIFICATION FOR Ti-its FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMI,1�,-r 45 FEE ❑ Surcharge FEE'- ❑ OtlierFEE _ <br /> INSPECTOR# JL v� PERMITVALID _ to j231-11) ❑ Food Handler_ <br /> Check# A 10UNT P e IID Xt t-Larb _ bate I14VOICF# .— <br /> -- <br /> ❑ Cash Pr;viEwFDBy ACCOUNT WG OFFICE _ — ate _— <br />