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M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility IDTA <br /> 1 Pro ram Record ID <br /> Facility Address CU LOC <br /> (Please heck the appropriate description and specify s__e number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required:. YFs❑ No❑ <br /> ❑ Commissary11Dry storage only 11with Food Preparation 11Vending Machines—Number of Units <br /> IJRetail 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(2000) <br /> ❑Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser Number of Containers in Multi-Head Unit <br /> _CUPA ❑State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) t. <br /> ❑Hazardous Waste Generator-=--- Tons Generated Per Year ❑Recycle I Exempt System(2299) <br /> ❑ CRT Offsite Handlers(221 s) ❑ Silver Only(2222) ❑Appliance Reeyolers(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 UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑Rotel/Motel Number of Units -❑Jail or Exempt Institution Number of Units <br /> Employee Housing(2700)Use Employee Housing-/Labor Camp Applicadoa Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑Environmental Assessment ❑UST-CAP Site ❑Local HW Cleanup Site• ❑NPLISEP Cleanup Site ❑UIC Site <br /> ❑Abandoned 11W Site ❑non-NPUSEP Cleanup Site ❑RWQCB Cleanup Site 13 Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑Pool ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm Maximum number of birds ❑Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) <br /> Tattooing(4121) ❑Body Piercing(4120) ❑Permanent Cosmetics(4122) <br /> IOUID 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 ❑Transfer Station ❑Ag/Cannery Waste Site ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑ ClALandfill 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'Nurs ng ❑Large Generator Q 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)UsePWSEHD 4&02-003 BlueAppllea(ion Form <br /> RGE CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph O' U�0 �'Gt C'' <br /> PROGRAMELEMENT4�jjaj,14110 FEE` ❑Surcharge FEE ❑ Other FEE <br /> INSPECTOR#4mixia IC4 PERMITVALID , to ❑Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEwWBY ACCOUNTING OFFICE Date �_... <br /> Mas erfle Record Pink <br />