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411-1 <br /> max= • � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am at Existing Facility ❑New EH Program and New Facility <br /> Facility )D - 1 I Program Record <br /> Facility Address • &9 ly I <br /> (Please Check the appropriate description and specify s•ize,number of units and pertineat information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Stating Capacity Square Footage Food Handlers Course required_. YFs❑ No ❑ <br /> [] Commissary ❑ Drystorage only ❑with Food Preparation ❑Nrending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prepackaged Goods Only <br /> [IMobile Food Vehicle---MVehicle Type Color <br /> ake Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> [3 Mobile Food Prep Unit--Make Licenst# Sticker# <br /> Registration# ❑ Ice Plant <br /> ❑Temporary Food Facility Dates of operation from to <br /> ❑-Product Stand <br /> [3 Special Event --Dates of operation from <br /> to <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)' i <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility-11 �nditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> -By-Rule Household Hazardous Waste <br /> [3permit-By-Rule Fixed Unit © <br /> ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B or rtr <br /> HOUSING PROGRAM(2440) <br /> ❑ <br /> ❑HotcilMotel Number of Units Jai!or Exempt Institution Number of Units <br /> )mployee nousiag(2700)Use Bnrpforee Housi%K4bor Camp Apyficv6en Form <br /> SITE MITIGATION(2900) - UNDERGROUND INJECT.ION CONTROL(3000) <br /> -E] Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site. ❑NPL/SEP Cleanup Site Ll UTC Site <br /> ❑Abandoned HW Site ❑non NPUJSEP Cleanup Site ❑R'%YQCB 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 13 Kennel. <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑Tattooing(412 1) [1 Body Piercing(4120) 13 Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAMS(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 1 CanneryWaste Site ❑ CIA-LandfSludge/Ashill <br /> Site <br /> ❑Waste Tire Facility ❑ Compost Facility ❑Process/Recycle Facility ❑ CIA Landfitl Site <br /> ❑Refuse Vehicles--Number of Units ❑Dumpsters>20 cu yd Number of Units ❑Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> 13 Primary Care ❑Acute Care ❑ Skilled'Nursing ❑Large Generator 0 Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑Veterinary Clinic ❑Common Storage Facility—X] 2-H) ❑ i 1-60----❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pli'S C1ID 46-02-003 Blue Application Form <br /> lEmr=PrENcY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEME1tiT FEE ❑ SurchargeFeE ❑ Other FEE <br /> INSPIECT0R#E'&3 Q PERMIT VALID to ❑Food Handler <br /> ❑ Cheek# AMOUNT PAID Date INVOICE# _ <br /> ❑ Cash REVIEWER BY ACCOUNTING OFFICE Date <br />