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SAN JOAQUIN COUNTY EN\,�ONMENTAL HEALTH DEPAR'I�..ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existin g Facili New EH Pro am and New Facility <br /> Facility IDD l7 Program Record ID _ �I p$ <br /> Facility Address G1A <br /> (Please Check the appropriate description and specify size,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: ..Seating Capacity .__ Square Footage _.._.__-........__-- ._.Food Handlers Course required:--YES-❑--NOD— <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 <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <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 /> CU PA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) <br /> . KHazardous Waste Generator----------Tons Generated Per Year CS � Q 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-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 forms <br /> HOUSING PROGRAM(2400) - <br /> '❑ Hotel/Motel-----Number of Units ❑ JailorExempt Institution—_Number of Units <br /> Employee Housing(2700) Use Employee Hoasine/Labor Camp Application Form <br /> . SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local 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) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIGUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> [IPumper Yard 11Package Treatment Plant 11Chemical 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—Number of Units ❑ Dumpsters>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care Cl Skilled Nursing ❑ Large Generator ❑Small Generator ❑ Limited Hauler <br /> ❑Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility-­0 2- 10--❑ 11 -60--❑>60 generators - <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02403 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> ,CONTACT PERSON I Day Ph Night Ph <br /> PROGRAM ELEMENT <br /> r7226 FEE � '13 Surchar eFE ❑Other FEE <br /> INSPECTOR# S l / PeRMrr VALID /� L�'t0 1 �/ El Food Handler <br /> ❑Check# - AMOUNTPAID 1l11.11.b Date 9f L(C INVOICE# - <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date 17/6 <br /> 48-02-034 <br /> 10/6/2003 MasterfileRecord Pink <br />