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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existin Facility ❑New EH Program and New Facility <br /> Facility ED F t Pro ram Record ID <br /> Facility Address(Please.Check Check the appropriate description and specify I!K�,number of udits and pertinent information.) <br /> T'OOD PROGRAM(1 500) <br /> ❑Restaurant: Seating CapacitySquare Footage Food Handlers Course required;. YEs❑ No❑ <br /> ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑Feuding 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 ❑ lee 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 /> w 4 GUPA ❑ State Facility Surcharge(2399) <br /> HAZARDOUS WASTE PROGRAM(2200) 1 <br /> ❑Hazardous Waste Generator. Tons Generated Per Year 1 ❑Recycle f Exempt System(2299) <br /> ❑CRT Offsite Handlers(2218) ❑Silver Only(2222) ❑Appliance Recyclers(2217) <br /> Tiered Permitting Facility ❑Conditionally Authorized(CA) ❑ Conditionally Exempt(Cir) <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 orms <br /> HOUSING PROGRAM(2400) <br /> ❑Rotel/Motel Number of Units ❑Jail or Exempt Institution—Number of Units <br /> Employee Iloasiag(2700)Use Employee HousinvZo Camp Analioation 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 MY 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 PooltSpa ❑Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farcy Maximum number of birds ❑Kennel <br /> TATTOO,BODY PIERCING,PERMANENT_COSMETIC PROGRAM(4100) <br /> ❑Tattooing(412 t) ❑Body Piercing(4120) ❑ Permanent Cosmetics(4122) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑Pumper Vehicle Registration# License# Capacity Vehicle-it <br /> Pumper Yard ❑Package Treatment Plant" ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PRo (4400) <br /> ❑Landfill ❑ Transfer Station ❑Ag/CanneryWaste Site ❑ Sludge(Ash Site <br /> ❑Waste Tire Facility ❑ Compost Facility ©Process/Recycle Facility ❑ CIA,Landrill Site <br /> ❑Refuse Vehicles--Number of Units ©Dulnpsfers>20 cu yd----Number of Units ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑Acute Care ❑ Skilled Nursing ❑Large Generator 0 Small Generator ❑Limited Hauler <br /> ❑ Transfer Station [3 Veterinary Clinic ❑ Common Storage Facility---D 2-10 ❑ 11-60—❑>60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS FUIn46-02-003 Blue Application Form <br /> EMERGENCY INOTINCATION Eon rHis FACILITY ANDIOR PROGRAM <br /> CONTACT]PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 417,t4,6 FEE ❑ Surcharge F ❑ Other FEE <br /> INSPECTOR# ERMIT VALID-. / // to /oq— 1 I ❑Food Handier r1 <br /> ❑ Check# AMOUNT PAID Dateft/ INVOICE# oC <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE late Q <br /> AR-M-MA M.,erl-ile Record Pink <br />