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SAN JICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> []New EH Program and New Facility <br /> ew EExistin FacilitFacilit ' U <br /> Pro ram RecordlD <br /> Eacitity Address <br /> (please Check the appropriate description and specify s'ue•number of units and pertinent information.) <br /> FOOD PROGRAM(1600) Food Handlers Course required:. Yrs❑ No ❑ <br /> [I Restaurant: Seating Capacity. Square Footage - <br /> umber of Units <br /> ❑ Commissary ❑ Dry storage only ❑with Food❑Pr with Mea ❑Vending MaEhines—N <br /> Meat Market Only [I Multiple Departments ❑ Prepackaged Goods Only <br /> [3 Retail Market--Square footage Vehicle Type Color <br /> ❑ Mobile Food Vehicle---Make License# Stickec# �.-- <br /> Registration# Vehicle Type Color <br /> ❑ Mobile Food Prep Unit—Make License# <br /> Registration# [3to Ice Plant <br /> ❑ Temporary Food Facility—Dates Of operation fromto ❑ produce Stand <br /> • Special Event —Dates of operation from <br /> DAIRYPRROGRAM(2000) ❑MilkDispeaser—NumberofContainers_inMulti-IleadUnit . <br /> Grade A Dairy [3 Grade B Dairy <br /> COPA ❑ State Facility Surcharge(2399) �� 6-e*\ I <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year <br /> Recycle I Exempt System(2299) <br /> ❑ Hazardous Waste Gcnerafor ❑ Silver Only(2222) ❑Appliance Reeyclers(2217) <br /> ❑ CRT Offsite Handlers(2218) ❑Conditionally Authorized(CA) ❑Conditionally Exempt(CE) <br /> Tiered Permitting Facility <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 LLC T A a� nd B forms <br /> HOUSING GPROGRAM(2400) ❑Jail or Exempt Institution—Number of Units <br /> ❑ HotetrMotel—Number of Units <br /> Employee Housing(2700)Use Emnlovee IlousinP/Labar Camn DERGROU Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> I,(SEP0) UIC site <br /> ❑Environmental Assessment O. ¢NPL/SEP CleaUST-CAP Site nup SiLocal ❑RWQCB HW cleanup Icleanup te ❑Site <br /> NPL(SE❑PWater Quality Remenup Site diation on S to <br /> ❑ Abandoned TINY Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> 13Ppol ❑ Spa <br /> ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> Number of Pools/Spas at Facility <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) License# Capacity Vehicle# <br /> [IpumperYehide—Registration# <br /> ❑ pumper Yard <br /> ❑Package Treatment Plant [I Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) ❑ Sludge/Ash Site <br /> [3Landfill ❑Transfer Station 13 Ag I Cannery Waste Site ❑ CIA Landfill Site <br /> 11 Process/Recycle Facility <br /> [I Waste Tire Facility [I Compost Facility [3Farm/Ranclr Cieanu Site <br /> El Refuse Vehicles—Number of Units ❑Dumpsfers>20 cuyd—Number of Units <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Smal(❑Gt'er6t0or o Limited60 generators <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility---D 2-10----- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use Pff SEND 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> Day Ph __— Night Ph <br /> CONTACTPERSON [I other FEE <br /> �1a [3Surcharge�.(FeE <br /> PROGRAM1t ELEMENT yFEE to l� El Food Handler <br /> INSPECTOR# Z PERMITVALID - <br /> ElCheck It AM1IOUNT PAID <br /> Date INvotcc# <br /> Date <br /> �t ACCOUNTING OFFICE <br /> El Cash I2EVIEWEfiBY (� p p (� V ' <br />