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STAN JOAQUIN COUNTY EN VIRON�IENTAL HEALTH DEPART- ANT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro am and New Facility <br /> New EH Program at Existing Facility <br /> �d b Program Record M <br /> Facility ID <br /> Facility Address= <br /> (Please Check the appropriate description and specify size,number r__f units and pertinent information.) <br /> FOOD PROGRAM(1600) Square Footage Food Handlers Course required: YES ❑ No ❑_ <br /> ❑ Restaurant: Seating Capacity q on ❑Vending Machines--Number of Units <br /> ❑ Commissar}' ❑ Dry storage l ❑ with Food Preparation <br /> g y C1 with Meat Market only ❑ Multiple Departments El Prepackaged Goods Only <br /> ❑ Retail Market - Square footage Color <br /> Vehicle Type Sticker# <br /> ❑ Mobile Food Vehicle-----Make License r <br /> Registration# Color <br /> Vehicle Type Sticker# <br /> [INlobile Food Prep Unit--Make License <br /> Registration# to C1 Ice Plant <br /> ElTemporary Food Facility-----Dates of operation from El Produce Stand <br /> El Special Event --Dates of operationto <br /> from <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade B Dairy El Milk Dispenser---Number of Containers in Multi-Head Unit <br /> C1 Grade A Dairy <br /> CUPA C1 State Facility Surcharge(2399) P-�-. 2226 <br /> f <br /> HAZARDOUS WASTE PROGRAM(2200) Tons Generated Per Year2S — J c> ❑ Recycle/Exempt System(2299) <br /> �Iazardous Waste Generator------------❑ Silver Only(222-'-) ❑ Appliance Recyclers (2217) <br /> ❑ CRT Offsite Handlers(2218) — ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> Tiered Permitting Facility-------------- ❑ Permit By-Rule Fired 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 ['STA and B forms <br /> HOUSING PROGRAM(2400) ❑ Jail or Exempt Institution----Number of Units <br /> ❑ Hotel/Motel-------Number of Units <br /> Employee Housing(2700) Use Emplolee Flor,sin�ILabor Camp Application Form <br /> UNDERGROUND INJECTION CONTROL(3000) <br /> SITE MITIGATION(2900) SitNPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Environmental Assessment C1UST-CAP Site ❑ Local HNN'Cleanup e ❑ <br /> C1non-NPL/SEP Cleanup Site [3RNN'QCB Cleanup Site [I Water Quality Remediation Site <br /> ❑ Abandoned HW Site <br /> RECREATIONAL HEALTH PROGRAM(3600) 0 Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> [I Pool ❑ Spa(3600) out of Service PoollSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> [1Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License Capacity Vehicle# <br /> # <br /> [3 Pumper Vehicle--Registration# ❑ Package Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> C] pumper Yard <br /> E PROGRAM(4400) ElSludge/Ash Site <br /> SOLID WAST <br /> ❑ Transfer Station ❑ Ag/Cannery Waste Site C3 CLA Landfill Site <br /> ❑ Landfill ❑ Process/Recycle Facility <br /> ❑ Compost Facility ❑ Farm/Ranch Cleanup Site <br /> IWaste Tire Facility P <br /> ❑ Dum <br /> ❑ Refuse Vehicles--Number of Units <br /> psters>20 cu yd----Number of Units <br /> MEDICAL WASTE PROGRAM(4500) ❑ Small Generator ❑ Limited Hauler <br /> ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ >60 generators <br /> ❑ Primary Care ❑ 2- 10-------❑ 11 -60------ <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> C] Common Storage Facility----- <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PPIS EHD 46-07-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PRO NRAMightPh <br /> Day Ph <br /> CONTACT PERSON ❑ Other FEE <br /> QQ � -7 �Z ❑ Surcharge FEE <br /> PROGRAMELEMENT FEE U to 2 ❑ Food Handler�— <br /> PERMIT VALID D <br /> INSPECTOR# Date INVOICE# y, <br /> [3 Check# REVIEWED ANIOUNT PAID =' Date ( t1J <br /> BY ACCO[JNTiNG OFFICE Masterfi <br /> ❑ Cash a Record Pink <br /> 48-02-034 <br />