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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facilit j ID ,� Program Record ID `7 <br /> Facility Address Z ✓ t��"?t/✓ / <br /> (Please fleck the appropriate description and specify EjEs number of units and pertinent information) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquareFootage Food Handlers Course required:. Yrs❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Vending 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 0 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 Dispeuser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 1 <br /> ❑Hazardous Waste Generator Tons Generated Per Year ❑ Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221s) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pemtit-By-Rule Fired Unit ❑Pe 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(arms <br /> HOUSING PROGRAM(2400) - - - <br /> ❑Hotel/Motel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Fmplovee Housinp/Labor Camp Applieaeioa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑USP-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site ❑UIC Site <br /> ❑ Abandoned IIW 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 D Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) " <br /> 13 Poultry Farm—Maximum number of birds _ 11 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 it Capacity Vehicle# <br /> ❑Pumper Yard —Iff Package Treatment Plant ❑ Chemical Toilets—Number of Units - <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landoll ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash 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 ❑ FarmlRauch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ SkilledNursing ❑Large Generator ❑ Small Generator ❑Limited Iiauter <br /> ❑Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility—❑ 2-10—❑ 11-60—❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PNS CIID 46-01-003 Blue Appficaeion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON O Day Ph Night Ph <br /> PROGRAM ELEMENT �.D �� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR / O PERMIT VALID . to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# _ <br /> ❑ Cash REVIEWED By ACCOUNTING OFFICE Date <br />