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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION MASTERFLE RECORD INFORIMATION FORM(EH 00 69) New EH Program at Existing Facility C( 1 ❑New EH Program and New Facility Facility ID �A Program Record ID l 9 Facility Address] (Please Check the appropriate description and specify si , number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: Yrs❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units ❑ Retail Market----Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle----Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit—Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant ❑ Special Event - Dates of operation from to ❑ Produce Stand DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi-Head Uni[ CUPA ❑ State Facility Surcharge(2399) HAZAI$DOUS WASTE PROGRAM(2200) a _ Hazardous Waste Generator------�'----------Tons Generated Per Year J Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste =VEGROUND STORAGE TANK FACILITY(AST)(2390)—Number of AST_ _ — UNDERGROUND STORAGE TANK(UST) PROGRAM(2300)Use UST A and 8(arms HOUSING PROGRAM(2400) ❑ Hotel/Motel-------Number of Units ❑ Jail or Exempt Institution—Number of Units Employee Housing(2 700) Use Employee Housh,/labor Camp 4onlication Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm—Maximum number of birds ❑ Kennel TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(412 1) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑All/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd —Number of Units ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility --❑ 2- 10—❑ 11 -60—❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EH0069 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM CONTACT PERSON Day Ph Night Ph 00 PROGRAM ELEMENT o 0 FEE,# DC) ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date / 1 EH 0069 PINK FORM.doe Rev.01/07;99