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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility Address <br />(Please heck the appropriate d@scriptiou and specify eLTe number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: <br />Seating Capacity <br />Square Footage <br />Food handlers Course required:.. YEs ❑ NO ❑ <br />❑ Commissary <br />❑ Dry storage only <br />❑ with Food Preparation <br />❑Wendiag Machines —Number of Units <br />❑ Retail Market <br />----Square footage <br />❑ with Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle ----Make Vehicle Type <br />Registration # License # <br />❑ Mobile Food Prep Unit—Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility -----Dates of operation from to <br />❑ Special Event —Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />Sticker # _ <br />_ Color _ <br />Sticker # <br />❑ Ice Plant <br />❑ Produce Stand <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) a <br />❑ Hazardous Waste. Generator- Tons Generated Per Year ❑ Recycle I Exempt System (2299) <br />❑ CRT Offsite Handlers (2218) ❑ Silver Only (2222) ❑ Appliance Recyclers (2117) <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 />❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Frnployee IlousinglLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(30W) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site. ❑ NPLISEP Cleanup Site ❑ UIC Site <br />❑ Abandoned 11W Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ 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) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License # <br />❑ Pumper Yard ❑ Package Treatment Plant• <br />SOLID WASTE PROGRAM (4400) <br />❑ Permanent Cosmetics (4122) <br />Capacity Vehicle # <br />❑ Chemical Toilets Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag I Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles --Number of Units 0 Dumpsters > 20 cu yd ----Number of Units <br />❑ Sludge/Ask Site <br />❑ CIAiLandfill Site <br />❑ FarnvRanct Cieauup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing 17 Large Generator D Small Generator ❑ Limited hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility -----D 2 -10 ❑ 11- 60 -----❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) UsePH'SEHD 46-02-003 BlueApplicadan Form <br />CONTACT PERSON <br />Day <br />F -- <br />Night Ph <!`r W` Z!•- <br />PROGRAM ELEMENT41 FEES "❑ Surcharge FEE i ❑ Other FEE <br />INSPECTOR # PERMIT VALID to ❑Food Handler <br />❑ Check # AMOUNT PAID Date INVOICE # ;7,,3 <br />❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br />Pink <br />