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SAN JOAQUTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD-INFORMATION FORM <br /> ew EH Program at ExistingFacility []New EpH Program and New Facility <br /> Facilit ID Q Program Record ID 1 �•QU S <br /> Facility Address <br /> (Please Check the appropriate description and specify size 9 number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ 11 with❑ Dry storage only ith Food Preparation ❑Fending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑Multiple 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 /> ElTemporary Food Facility-----Dates of operation from to ❑ Ice Plant <br /> [3 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 /> GTPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200)' i <br /> ❑Hazardous Waste Generator.. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(221 7) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Permit-By-Rule Fixed Unit C❑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 farms <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotellll'Iotel Number of Units "❑Jail or Exempt Institution Number of Units <br /> Employee Dousing(2700)Use Fmployee Horrsine/Labor Camp Applicafian Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site 17 Local IIW Cleanup Site, ❑NPIJSEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑ non-NPLISEP 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 /> 11Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant. ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> El Landfill E] Transfer Station 11 Ag I Cannery Waste Site 11 SludgeJAsh Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑ProcessRecycle Facility ❑ CIA-Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd Number of Units ❑FarmlRauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care Skilled Nursing 11 Large Generator D Small Generator 11 Limited Hauler <br /> El Station 11 Veterinary Ctin c ❑ Common Storage Facility--❑ 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)UscPff'SEAD 46-02-003 BlueApplica(ian Form <br /> EMERGENCY{NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON_ 1 _ j� _ Day Ph Night Ph <br /> PROGRAPiELENIEN-r �"115� FEE l/ 11Surchar eFEE -- ❑ 011ier FEE <br /> INSPECTOR# 6SL PERMIT VALID l 3_ to Ca 3�I13 ❑ Food Handler_ <br /> -❑ Check f, AMOUNTP AJD _ 'Date INVOICE ff _-- <br /> ❑ <br /> Date <br /> Cash i�VIEW D BY �(.p CS_ ACCOUNTING i1FFICE <br />