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rSfANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Pro am at Ex's <br /> Facility <br /> ❑New EH Pro and New Facility <br /> Facilit ID rA Pro ram Record ID <br /> Facility Address <br /> (Please Check the appropriate description and specify�num a of units and pertinent information.) <br /> FOOD_ PROGRAM(1600) Food Handlers Course required:.. Yes❑ No❑ <br /> ❑Restaurant: Seating Capacity Square Footage <br /> ❑\'e¢di¢g Machines—Number of Units <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation prepackaged��Only <br /> ❑Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑Prep <br /> Vehicle Type Color� <br /> ❑ Mobile Food Vehicle—Make License# Sticker# �— <br /> Registration# - Color <br /> Vehicle Type Sticker# �— <br /> ❑Mobile Food Prep Unit—Make License# <br /> Registration# to ❑Ile Plant <br /> ❑Temporary Food Facility-----Dates of operation from to ❑Produce Stand <br /> ❑ Special Event —Dates of operation from <br /> DAIRY PROGRAM(2000) <br /> ❑Grade A Dairy <br /> ❑Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> - t)UPA ❑ State Facility Surcharge(2399) <br /> RAZARDOUS WASTE PROGRAM(?200) ❑Recycle/Exempt System(2299) <br /> ❑Hazardous Waste Generator. Tons Generated Per Year ❑ Appliance Recyclers(2217) <br /> ❑CRT Offsite Handlers(2218) ❑ Condi Only(222th PP <br /> Tiered Permitting Facility <br /> ❑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 /> ` <br /> 5 UNDERGROUND STORAGE TANK(USI)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) - <br /> ❑HoteUMotel Number of Units ❑JAIor Exempt Institution umber of Units <br /> Employs Ilousing(2700)Use Employee Nousin¢/Labor Camp Application Form <br /> SITE MIS ION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> LISEP Cleanup Site <br /> [IEuviroamental Assessment �¢ NPLISEP p Site <br /> Site. ❑ <br /> ❑RWQCB CleanupSi eP ❑Water Quality Remediation Site <br /> ❑Abandoned IIW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) 0 Out of Service Pool/Spa ❑Natural Bathing Area <br /> Number of Pools/Spas at Facility. ❑Yoot El Spa <br /> VECTOR CONTROL PROGRAM(40011) ❑Kennel <br /> ❑Poultry Farm—Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETICPROGRAM(4100) ❑permanent cosmetics(4122) . <br /> ❑Tattooing(4121) ❑Body Piercing(4120) <br /> LIQUIDWASTE PROGRAM(4200) Capacity Vehicle# <br /> C3 pumper Vehicle—Registration# �— L70 0# <br /> tPlant ❑CheaucalToilets—NumberofUnits <br /> [3 pumper Yard ❑PackageTreatmea <br /> �— <br /> SOLID WASTE PROGRAM(4400) ❑A /Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑Landfill ❑Transfer Station g ❑ CIA,.I,andCdl Site <br /> ❑Process/RecycleFacility <br /> ❑Waste Tire Facility [ICompost Facility ❑Farm/Rauch Cleanup Site <br /> ❑Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units <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--[3 2-10—❑ 11-60_❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PH'S EUD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph�— Night Ph <br /> CONTACT PERSON ❑ Other FEE <br /> ❑ Surcharge FEE <br /> PROGRAM ELEMENT FEE------ ❑Food Handler <br /> INSPECTOR# PERMIT VALID t0 INVOICE# <br /> AMOUNT PAID Date <br /> ❑ Check# Date <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE <br /> b(��wrflr R.rnrA Pink <br />