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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM _ <br /> ❑New EH Program al Existin Facility KNew EH Program and New Facility <br /> Facilit•ID d e�;)636�_ Pro ram Record ID L) <br /> Facility Address - -\\M <br /> (Please Check the appropriate description and specify size,n ber of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES❑ No ❑ <br /> ElCommissary 13Dry 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---Mal=e Vehicle Type Color <br /> Registration# License# Slicker# <br /> ❑ Mobile Food Prep Unit—Make Veliicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special EYeat --Dates of operation from to ❑Produce Stand <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Numbcr of Containers in Multi-Ilcad Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200) <br /> ❑Ilazardous Waste Generator-- Tons Generated Per Year ❑ Recycle I Exempt Systern(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑ Appliance Reeyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-By-Rule Fixed Unit ❑Pernut-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(arms : <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Fmplol•ee Ifousint•/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAF Site ❑ Local MV Cleanup Site. ❑ NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IINV 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 El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ 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/Cannery Waste Site ❑ Sludge/Ask 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 ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facilit)•---D 2- 10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)(Ise PHIS EHD 46-01-003 Mac Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AHD/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELFNIENT q7'/V V FEE ❑ Surcharge FEE ❑ O(tier FEE <br /> INSPECTOR# PEF1,11TVALID to ❑Food Handler <br /> ❑ check# AmOUNT PAID Date lrwo1CL it _ <br /> ❑ Cash REVIEW ED BY ACCOUNTING OFFICE Date <br />