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r 1 � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facili (Ueyr,EH,Prrxtari,NewyF:_.,acfli <br /> � , a vta <br /> Facility IID <` . Program Record ID <br /> � IrN? i � `� i /✓� <br /> (Pleasecheckthe appropriate description and specify size,number of units and pertinent 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 ❑ 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 Containert in Multi-Head Unit <br /> IS"- <br /> (2200) •' �' �'�x <br /> TE PROGRAM <br /> - <br /> ❑ <br /> ^{�►� Recycle/Exempt System(2299) <br /> HAZ <br /> WASFte Handlers(2218} -- ----------❑ Silver Only(2222) ❑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 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 Employee Housina/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP 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) ❑ 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 ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch Cleanup Site <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing Karge4Generator ❑ Small Generator El Limited Hauler <br /> ❑ Transfer Station El Veterinary Clinic ❑ Common Storage Facility'❑ 2- 10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Avvlication Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> C9 TgCT�Fs01V tayFrd�fil`/d' Night Pt1y + A� 37 <br /> w . .... .. __. <br /> PROGRAM ELEMENT FEE ❑ Surcharg�FEES_ ❑ Other FEE <br /> INSPECTOR# PERMIT VALID C _ to 4Z, ❑ Food Handler <br /> s t. <br /> ❑ Check# AMOUNT PAID ` ,< ¢ { Date INVOICE# f f ' <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE <br /> �:' Date �'/ ; !,� <br /> 034 <br /> 1/15/ <br /> 1 07 MASTERFILE RECORD INFORMATION PINK <br /> 11/15/ <br />