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- <br /> SAN JOAQLIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility A ddrcs5 ( rz pi's lZr� <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:. Yss® NO El <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Veading Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Yehicie--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> [I Temporary Food Facility----Dates of operation from to [I Ice Plant <br /> ❑ Special Event —Dates of operation from to 11 Product Stand <br /> e <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 IVASTE PROGRAM(2200)' f <br /> ❑hazardous Waste Generator.. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pen-nit-By-Rule Fixed Unit Cl Permit-By-Rule Household Hazardous Waste <br /> ❑ABOVEGROUND STORAGE TANK FACILITY(AST).(2390) Number of AS T <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> [IIlotenlotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Employee housing(2700)Use Employee Houser,=/Labor Carr p Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> 13Environmental Assessment ❑UST-CAP Site 11Local MV Cleanup Site, ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned HW Site ❑ nou-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(4 120) ❑Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> El Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant- ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landfill 13 Transfer Station ❑Ag I Cannery Waste Site 11 Studge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA-Landfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsfers>20 cu yd—Number of Units ❑Farm/Rauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Stalled NursingLarge Generator D Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—A] 2-10 ❑ 11-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PN`SEKD 4642-003 BlueApplica[ion Form <br /> EMERGENCY NOTIFICATION FOR'rms;FACILITY ANO/OR PROGFZAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRANIELENIEr,m FEE 19 J ❑Surcharge FEE ❑ Other FEE — <br /> INSPECTOR# =7 �—_ PERMIT VALID I I to MR t 11 ❑ Food Handler— <br /> 11 Check Y AMOUrt"r P.d ID . l( ­ <br /> Date lrtvolCE# A <br /> `t <br /> 0 Cash I,'.r-,VIFWFD BY Accot>mrw-,OFFICE _—� Date _- <br />