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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARThmi NT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH ProoM at Existing Facility UNew EH Program and New Facility <br />Facilit • ID D 0 O 1. 1 O 6 Pro ram Record ID S �g <br />Facility Address os s, r -- <br />(Please heck the appropriate description and specify EjM number of units andtertineut information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yrs ❑ 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 # Licence # 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 Dispeaser—Number of Containers in Multi -Head Unit <br />COPA ❑ State Facility Surcharge (2399) <br />HAZARDOUS WASTE PROGRAM (2200)' { <br />❑ Hazardous Waste Generator. Tons Generated Per Year ❑ Recycle [Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ 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 />❑ HotcVMotel Number of Units ❑ Jail or Exempt Institution Number of Units <br />Employee housing (2700) Use Employee IffousirreEabor Camp Apalicatiore Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) _ <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local BW Cleanup Site. ❑ NPLFSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLFSEP Cleanup Site ❑ RWQCB Cleanup Site ' ❑ Water QualityRemediatiou Site' <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _,L— XjkP901 ❑ Spa E.3 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 I Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ FarmFRauch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care * ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--❑ 2 -10 — ❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PIES ELM 46-02-003 Blue Application Form <br />CONTACTPERSON <br />Day Ph ,!j .5 ( — 77CM7LNight Ph <br />PROGRAM ELEMENT FEE `-- ❑ Surcharge FEE' ❑ Other FEE <br />INsrecron# PERMIT VALID . 2 F. O to 13ll 0$ 11 rood Handler <br />❑ Check# AMOUNT PAID Date INVOICE# p' <br />0Cash REVIEWED BY ACCOUNTING OMCE -&(— Date G'I /c7Q <br />