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SAN JOAQUIN COUNTY VIRONMENTAL HEALTH DEPAENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility ❑New EH;Program and New Facility <br /> Facilit lD <br /> Program Recor ID <br /> Facility Address 2- �I S U/✓!d <br /> (Please check the appropriate description and specify size, number of units and ertinent information.) <br /> FOOD POGRAM R (1600) <br /> 13 Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No <br /> ber of Units_ <br /> ing Machines Num <br /> ❑ Commissary ❑ Dry storage only with Food❑Pw Preparation <br /> t Market only [:1 Multiple Departments[] Prepackaged Goods Only <br /> ❑ Retail Market----Square footage Color <br /> ❑ Mobile Food Vehicle--Make Vehicle Type <br /> Registration# License# Sticker# <br /> Vehicle Type Color <br /> ❑ Mobile Food Prep Unit Make Sticker# <br /> Registration# License# <br /> ❑ lant <br /> Temporary Food Facility--Dates of operation from to ❑ Ice <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-----------Tans 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) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By- 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 forms Z <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700)Use Employee Housing/Labor Camp ADOlication Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> El Environmental Assessment ❑ UST-CAP Site 11 Local HW Cleanup Site ElNPUSEP Cleanup Site El UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> ❑ <br /> Number of PooWSpas at Facility El Pool ❑ Spa Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ 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 /> ❑ 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 1:12-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHO 46-02-003 Blue_Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT_ 1140 1 FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR#C'�JOI G PERMITVALID t0 ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 1!9 <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 11115/07 <br /> 1 <br />