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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA.RTmENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br />Facility ID F /3 C X! i c c) Program Record ID DDw 52S-7 7 Z— <br />Facility Address _(4 � <br />i a ' <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 ❑ with 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 />❑ 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 />IIAZARDOUS WASTE PROGRAM (2200) <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 -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 />❑ HoteUMotel Number of Units .❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP 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 (412 1) ❑ Body Piercing (4120) ❑ Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # Capacity <br />Vehicle# <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets <br />Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag / Cannery Waste Site <br />❑ Sludge/Ash Site <br />Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units <br />❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator D Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility---[] 2 - 10 <br />❑ 11- 60 -----❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use Pff'SEHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph <br />Night Ph <br />PROGRAM ELE111EiT L4 ti C_i FEE czx ❑ Surcharge FEE <br />❑ Other FEE <br />INSPECTOR # 3 "Z4 PERMIT VALID to <br />❑ Food Handler <br />❑ Check A111OUNTPAID A Date <br />INVOICE# <br />❑ Cash REVIEWED BY �� 11 / / / 0 ACCOUNTING OFFICE <br />Date <br />