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_ r i • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 114 , <br /> MASTERFILE RECORDINFORMATION FORM <br /> ew EH Program at Exis[in Facility ❑New Ell Program and New Facility <br /> Facilit y ID Pro rant Record ID <br /> Facility Address 3y <br /> (Please Check the appropriate description and specify size, Iger oCunits and p rtinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant Seating Capacity Square Footage Food Handlers Course required: Yss❑ No ❑ <br /> ElCommissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines—Number of Units <br /> ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant <br /> ❑ Special Event -Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(200 ) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser—Numbcr of Containers in Multi-Bead Unit <br /> CUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) i <br /> ❑ hazardous Waste Generator.-- Tons Generated Per Year 17 Recycle/Egempf S)sietti(2299) <br /> ❑CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Perrait-lay-Rule Fixed Unit ❑Pernut-By-Rule Household hazardous Waste <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Numbcr of AST <br /> UNDERGROUND STORAGE TANK(UST)PROGRAM(2300)Use UST A and B(omrs <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Numbcr of Units ❑Jail or Exempt Institution Number of Units <br /> Eraeployee housing(2700)Use Fmployee HousirrzlTkbor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION C014TROL(3000) <br /> ❑ EnAronmental Assessment ❑UST-CAP Site ❑ Local IBV Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned II`I Site [Inon-NPLISEP Cleanup Site ❑RNIrQCB Cleanup Site 'I]Nater Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PooWSpas at Facility. ❑Pgol ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> [IPoultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4 120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle.# <br /> ❑ Pumper Yard ❑ Package Treatment Plante ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> aste Tire Facility ❑ Compost Facility ❑ ProcessfRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsfers>20 cu yd—Number of Units ❑ Farm/lUnch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Mauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility—El 2-10 ❑ 11 -60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PlfiSEIM 46-02-003 Mae Apphcalion Form <br /> EMERGENCY NOTIFICATION FORTHIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph --— <br /> PRoGRAm ELEMENT���� FEE El Surcharge FEE [I other FEE <br /> INSPECTOR# ab PERMITVALID to ❑ Food liandler <br /> El Check g AMOUNT PAID Date INVOICE f€ <br /> ❑ Cash REV1E\1'F_D BY ACCOUNTING OFFICE D a te v <br />