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SAN JOAQUIN COUNTY`-VIRONMENTAL HEALTH DEPA ENT <br /> y MASTERFI�ECORD INFORMATION FORM <br /> ❑New EH Pro ram and New Facilit <br /> ❑ New EH Program at Existing Facilit _ <br /> r� C- program Record ID c <br /> Facilit lD <br /> Facility Address 1 ` <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course reguired: YES ❑ No ❑ <br /> 0 Restaurant: Seating Capacity Square Footage �^ <br /> ❑ Commissary ❑ Dry storage only [I with Food Preparation ❑Vending Machines Number of Units <br /> 1:1 Retail Market----Square footage- ❑ with Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> El Mobile Food Vehicle--Make License# Sticker# <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit Make <br /> License# Sticker# <br /> Registration# to [j lee Plant <br /> ❑ Temporary Food Facility--Dates of operation from to ❑ Produce Stand <br /> ❑ Special Event Dates of operation from <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 <br /> eCle/ xec p System <br /> tem(2299) <br /> 1:1 CRT Offsite Handlers(2215) ----------- El Silver Only(2222) Appliancey <br /> Tiered Permitting Facility------------------- ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By Household Hazardous Waste <br /> IxABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST y <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300) Use USTA and B forms <br /> HOUSING PROGRAM (2400) <br /> El Hotel/Motel--Number of Units ❑ Jail or Exempt Institution---Number of Units <br /> Employee Housing(2700) Use Em !o ee Housin 1Labor Cam A !lcafion Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds EI 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 Veh icle Reg istration# 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/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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600)Use PWS EHD 4b-02-003 Blue Application Form <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# ' PERMIT VALID to 11Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date p <br /> 46-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/07 <br />