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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR`T'MENT <br /> MASTERFILE RECORD INFORMATION FORM — <br /> ❑New EH Program at Existin Facility .!thew Ell Program and New Facility <br /> Facility ID Q b? Program Rec rd ID <br /> Facility Address <br /> (Please Check the appropriate description and specify size•number of units and perti nt information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food handlers Course required: YES❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending 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 El ice Plant <br /> ❑ Special Event —Dates of operation from to ❑ Produce Stand <br /> DAIRY PROGRAM(2000) <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 ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite handlers(2219) ❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑ Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) <br /> ❑Pcrmit-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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ IIote"lotel Number of Units ❑Jail or Exempt Institution Number of Units <br /> Emptoyee Ifousing(2700)Use Fmpfoyee Mousinc/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑UST-CAP Site ❑ Local MV Cleanup Site. ElNPLISEP Cleanup Site 11 UTC Site <br /> ❑ Abandoned IIIV Site 13non-NPIJSEP Cleanup Site 11R\i'QCB Cleanup Site ❑Nater Quality Remediation Site- <br /> RECREATIONAL <br /> iteRECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑ Out of Scrtiice Pool/Spa ❑ Natural Bathing-Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm Maximum number of birds El Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> ❑ Tattooing(4121) ❑ Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill 11 Transfer Station 11 Ag I Cannery Waste Site ❑ Sludge/AsL Site <br /> 9-lYaste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles—Number of Units ❑ Dumpsters>20 cu yd—Number of Units ❑ Farm[Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited IIauler <br /> 11 Transfer Station 11 Veterinary Clinic 11 Common Storage Facility—[] 2-10—[III-60--❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PIIS FIID 46-02-003 Blue Application Form <br /> EM11ERGENCY NOTIFICATION FOR THIS FACILITY ANDIOR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT '1730 FEE ❑ SurcLarge FEE ❑ Other FEE <br /> INSPECTOR# 22 PERMIT VALID . to ❑ Food handler <br /> ❑ Ct,eck it AMOUNT PAID Datc _ INVOICE# _ <br /> ❑ Cash REVIEWED BY __ ACCOUNTING OFFICE Date <br />