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• <br />• <br />-SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facilit ID 4 Pro ram Record ID <br />Eaciliiy Address <br />4' <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD: PROGRAM (1600) <br />❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. Yrs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑'ending Machines Number of Units <br />❑ Retail Market—Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle -Make <br />Registration # <br />❑ mobile Food Prep Unit -Make <br />Registration # <br />❑ Temporary Food Facility- Dates of operation from <br />� ❑ Special Event =Dates of operation from to ❑ Produce Stand <br />�.r.w�ov oconr_on�ur'L'�(1r1(11 . <br />Vehicle Type <br />License # _ <br />Vehicle Type <br />License # <br />_ Color <br />Sticker # <br />_ Color <br />Sticker # <br />to ❑ Ice Plant <br />❑ Grade B Dai ❑ Milk Drs ser Number of Containers in Multi -Head Unit <br />Grade [I �. -• Dairy Pen - <br />COPA ❑ 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) ❑ Silver Only (2222) -w ❑ Appliance Recyclers (2217) <br />Tiered Permitting -Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />x❑Permit-By-Rule Fixed Unit 11Permit-By Rule Household Hazardous Waste <br />• ❑ABOVEGROUND STORAGE TANK FAci LTTY (AST) (2390) Number of AST <br />",.,UNDERGROUND- STORAGE TANK (UST) PROGRAM (2300) Use UST A and B forms <br />HOUSING PROGRAM (2400) <br />❑ HofetfMotel —Number of Units .❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee (lousing-lLabor Camp Application Form <br />SITE'MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />l] Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site, ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned MY Site 11non-NPLISEP Cleanup Site 11RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of PoolslSpas at Facility . 1:1 P901 11 spa ❑ Out of Service PoollSpa ❑Natural Bathing Area <br />'• VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds ;{ ❑ Kewt l <br />iTATT00 BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />Pub <br />7 Tattooing(412Rr9'S3� Body Piercing (4120) Q, -$ Permanent Cosmetics (4122) <br />LIQUID WASTE P_ROGRAM'(4(200) l� <br />1:3 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-Landrill 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 ❑ Sld 1414urs'ing ❑ Large Generator ❑ Small Generator ❑ Limited Mauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --0 2 -10 ❑ 11- 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use FIES EHD 46-02-003 BlrreApplication Form <br />% EMERGENCY NOTIFICATION FORTHIs FACT ITY AND/OR PROGRAM �� o <br />CONTACT PERSON / %�%{ J �% f%1 i/ f f 1 ?,' i�ay Ph 2rt1 7-71- 353 Night Ph <br />py <br />PROGRAM ELEMENT FEE _ <br />INSPECTOR# PERMIT VALID <br />❑ Check # : AMOUNT PAID <br />Cash -- REVIEWEDBY <br />❑ SurchargeFEE"-- ❑ Other FE;E­ <br />to ❑ Food Handler <br />Date <br />OFFICE <br />INVOICE # <br />Date <br />