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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility []New EH Program and New Facility <br /> i. _ <br /> Facili ID <br /> Program Record ID I/�0 777 6 7 <br /> Facility Address <br /> (Please Check the appropriate description and specify size,number of units and pertinent informati(n.) <br /> FOOD PROGRAM(1600) <br /> Food Handlers Course required: Yes❑ No <br /> ❑ Restaurant. Seating Capacity Square Footage ❑Vendin Machines—Number of Units <br /> C1 Commissary ❑ Dry storage only ❑with Food Preparation g <br /> ❑ Retail Market----Square footage ❑ with Meat Market only ❑Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle-----Make License# Sticker# <br /> Registration# Color <br /> Vehicle Type <br /> ❑ Mobile Food Prep Unit--Make VeLicense# Sticker# <br /> Registration# to 11 lee Plant <br /> ❑ Temporary Food Facility-----Dates of operation from [I Produce Stand <br /> ❑ 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 /> COPA EfState Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> '�-OYt$ El Recycle/Exempt System(2299) <br /> [. Hazardous Waste Generator------------Tons Generated Per Year <br /> ❑ Appliance Rec clers(2217) <br /> [I CRT Offsite Handlers(2218) ❑ Silver Only(2222) PP y <br /> Tiered Permitting Facility-------—-------—❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-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(orntc <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution-----Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use EpmlOyee HousipE/Lalrpr Capes Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) „ <br /> ❑ Environmental Assessment ElUST-CAPSite 13Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW 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 ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm---Maximum number of birds <br /> TATTOO,BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle--Registration# <br /> License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑Package Treatment Plant ❑ Chemical Toilets------Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash a/Ash Sile <br /> ❑ Landfill LJ Transfer Station 11 Ag/Cannery Waste Site g <br /> ❑ Waste Tire Facility <br /> ❑ Compost Facility 1:1Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles--Number of Units ❑ Dumpsters>20 cu yd----Number 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 ----C3 2- 10-------011 -60------❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph '/LL Night Ph <br /> PROGRAMELEMENT ����% FEE 900 Surcharge FEE�Z� ❑ Other FEE <br /> IrvseEc'roa# <� Z�, - PERMIT VALID to <br /> //31 D /L` ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWEDBY AcCoutvnNo OFFICE Date <br /> Masterfile Record Pink <br /> 48-02-034 <br /> 10/6/2003 /�,_ ,( /, ^ ` �". /]// <br />