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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existin Facility ❑New EH Program and New Facility Facility ID V Pro ram Record ID P ` 7 Facility Address (Please Check the appropriate description and specify size•number of units and pertinent information.) C O oO 3S3 S• FOOD PROGRAM(1600) ❑Restaurant: Seating Capacity Square Footage Food Handlers Course required:. YES❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation 11 Vending Machines—Number of Units ❑ Retail Market—Square footage ❑with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle---Make Vehicle Type Color Registration# License# Sticker It ❑Mobile Food Prep Unit—flake Vehicle Type Color Registration# License# Sticker# ❑Temporary Food Facility-----Dates of operation from to ❑ Ice Plant ❑ Special Event —Dates of operation from to ❑Produce Stand DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑Milk Dispenser---Number of Containers in Multi-Iiead Unit COPA ❑ State Facility Surcharge(2399) HAZARDOUS WASTE PROGRAM(2200) y ❑ Hazardous Waste Generator---- Tons Generated Per Year ❑Recycle f Exempt System(2299) ❑ CRT Offsite Handlers(2218) ❑ Silver Only(2222) _ ❑Appliance Recyclers(2217) Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(CE) ❑Permit-By-Rule fixed Unit ❑Pem-dt-By-Rule Household hazardous Waste ❑ABOVEGROUND STORAGE TANK FACILITY(AST)(2390) Number of AST ICER QUND S K(UST)PROGRAM(2300)Use LIST A and B forms HOUSING PROGRAM(2460) (32Z. otcU& o e ❑Jail or Exempt institution Number of Units Employee housing(2700)Use Employee HousinzlEabor Camp Application Fornr SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑UST-CAP Site ❑Local IBV Cleanup Site. ❑NPLISEP Cleanup Site ®UIC Site ❑ Abandoned HSV Site ❑ non-NPL/SEP Cleanup Site ❑RWQCB Cleanup Site ❑ 'Yater Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Poc,WSpas at Facility ❑ Pool ❑ Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm Maximum number of birds ❑Kennel TATTOO BODY PIERCING.PERMANENT COSMETIC PROGRAM(4100) ❑ Tattooing(4121) ❑Body Piercing(4120) ® Permanent Cosmetics(4122) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle—Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant- ❑ Chemical Toilets Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑Transfer Station ❑Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ `Paste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA-Landfill Site ❑ Refuse Vehicles—Number of Units ❑Dumpsters>20 cu yd—Number of Units ❑ FarmlRauch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ® Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ® Veterinary Clinic ❑ Common Storage Facility—11 2-10 ® 11-60--❑>60 generators PUBLIC WATER SYSTEM PROGRAM(4600)UsePII'SEMD 46-02-003 BlueApplica(iort Form EMERGENCY NOTIFICATION FOR THIS FACILITY AtMtOR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRANiELEn1ENT_A_3_Z? FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR#( PERMIT VALID to ❑ Food Handler ❑ Check Y All%OUNT PAID Date INVOICE# _ 0Cash IZEVIL-WEDBY ACCOUNTING OFFICE �� Date �� 1�