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SAN9JOAQUIN COUNTY.��fIRONMENTAL HEALTH DEPART NT <br /> MASTERFILE-RECORD INFORMATION FORM II <br /> ❑ New EH Program at Existing acility ❑New EH Program and New-Fac t <br /> Facility ID Program Record ID p o IE <br /> Facility Address <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) �I <br /> FOOD PROGRAM (1600) it <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course rewired: YES❑ 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 11 <br /> Registration# License# Sticker# !I <br /> ❑ Mobile Food Prep Unit Make Vehicle Type Color <br /> Registration# License# Sticker# �I <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 /> HAZARDOUS WASTE PROGRAM(2200) <br /> ❑ Hazardous Waste Generator----------- Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ------------ ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility - ❑ Conditionally Authorized(CA) ❑ Conditionall mpt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By ule usehold Hazardous Waste <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST / <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use UST A and B form <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution- mber of Units �M <br /> Employee Housing(2700) Use Em to ee Housing/Labor Camo A lication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) I' <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑'UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> I' <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> a <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel I <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) II <br /> I <br /> ❑ Tattooing(4121) ❑ Body Piercing (4120) ❑ Permanent Cosmetics,(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> Pumper VehicleRegistration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units 11 <br /> .r <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Farm/Ranch 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 Facility 1:12- 10 011 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form II <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# 06SI�/tpPERMIT VALID t0 ❑ Food Handler �E <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE DateVr�(Q <br /> L <br /> li <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/67 ii <br />