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SAN JOAQUIN COUNTY ENVIRONM,I•;NTAL HE 11 DEPARTM 7N <br /> T <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Pro ram al ExistiIt Facility ❑New EH Pro and New Facili ' <br /> FacilitYID O � ��lF.�� Pro ram Record ID � ���� � C� <br /> hacility Address �l Al /r v <br /> (Please Check the appropriate description and specify size'number ofunits and nertinen(informatioo.) �/ <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. Yes❑ No 11 <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines—Number of Units <br /> ❑Retail Market—Square footage ❑with Meat Markel only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> i ❑Mobile Food Vehicle--Make Vehicle Type Color <br /> Registration# License# Sticker It. <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color ' <br /> Registration# License ft Sticker# <br /> ❑Temporary Food Facility---Dates of operation front to 1:1 Ice Plant . <br /> [3Special Event —Dates of operation from - to ❑Produce Stand <br /> DAIRY PROGRAM (2000) - <br /> ❑ Grade A Dairy 3 Grade B Dairy ❑Milk Dispegser—Number of Containers in Multi-Head Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> IIAZARDOUS WASTE PROGRAM(2200)` ! <br /> ❑ Hazardous Waste Generator.--Tons Generated Per Year ❑ Recycle/Exempt System(2299) <br /> ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) s ❑ 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 USTA and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Hotel/Motel—Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Ffousine/Lahor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL 3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑Local HIV Cleanup Site. ❑NPLISEP Cleanup Site ❑ UTC Site <br /> ❑Abandoned 11W Site ❑non-NPUSEP Cleanup SIte ❑RWQCB Cleanup Site ❑Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number ofPools/SpasatFacility. 11 Pool ❑ Spa DOut ofService Pool/Spa ❑ Natural ItathiagArea <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) - <br /> ❑ Tattooing(4f21) ❑Body Piercing(4120) ❑PermancatCosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) - <br /> ❑ Pumper Vehicle—Registration# License# CapacityVehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plaut ❑Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> 11 Landau ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> 51 Waste Tire Facility ❑ Compost Facility ❑ Process/RecycleFaellity 11CIALandfill Site <br /> ❑Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑FarmtRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ PrimaryCare * ❑Acute Care ❑ Skilled Nursing ❑Large Generator ❑ Small Generator ❑ Limited hauler <br /> ❑ Transfer Station ❑Veterinary Clinic ❑ Common Storage Facility-0 2-16—❑ t 1-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use r1l'S EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFIOATiON FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEhIENT y U FEE pJ ❑ Surcharge FEE '. ❑ Other FEE <br /> INsreeroR# I-:) PERMIT VALID . to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date ,, / INVOICE# <br /> r] cash REVIEWE➢BY )/� ll1,2C9//D ACCOUNTING OFFICE �.y"Date <br />