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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP <br />MASTERFILE RECORD INFORMATION FORM <br />aNew EH Program at Existing Facility ❑New EH Program and New Facility <br />Facilit • ID Pro ram Record ID <br />Facility Address <br />(Please Check the appropriate description and specify size, number of units and pertinent information.) <br />M <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required.. YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Fending Machines -Number of Units <br />❑ Retail Market —Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make <br />Registration # <br />❑ Mobile Food Prep Unit -Make <br />Registration # <br />❑ Temporary Food Facility—Dates of operation <br />❑ Special Event —Dates of operation from <br />from <br />Vehicle Type <br />Color — <br />License # <br />Sticker # <br />Vehicle Type <br />Color _ <br />License # <br />Sticker # <br />to <br />to <br />❑ Ice Plant <br />❑ Produce Stand <br />DAIRY PROGRAM (2040) <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) ' t <br />❑ Hazardous Waste Generator.-- - Tons Generated Per Year _ ❑ Recycle / Exempt System (2299) <br />❑ CRT Offsite Handlers (2219) ❑ Silver Only (2222) ❑ Appliance Reeyclers (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 IIousing&abor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL( 000 <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local IIW Cleanup Site. ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned I1`'Y Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site T ❑ Nater 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 />FTattooing (4121) ❑ Body Piercing (4120) <br />QUID 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 / Cannery Waste Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />❑ Refuse Vehicles -Number of Units _ ❑ Dumpsters > 20 cu yd Number of Units <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Sludge/Ash Site <br />❑ CIA.Landfill Site <br />❑ FarnVRauch Cleanup Site <br />❑ Primary Care ❑ Acute Care ❑ SkilledNurs'Ing ❑ Large Generator 0 Small Generator ❑ Limited hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility--[] 2 -10 ❑ 11- 60 --❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) UseP►f'SEKD 46-02-003 Blue Application Form <br />A EMERGENCY NOTIFICATION FORTHIs FACILITY AND/OR PROGRAM <br />CONTACT PERSON �, V� �C ,' ,C�ULr Day Ph g( 22 -IQ G i '- t(V'Night Ph C6122 - ({ 01 - 074q <br />PROGRAM ELEN1ENrr _ FEE _ <br />INSPECTOR#fes✓ _ PERMITVALID <br />❑ Check it ABtOUNT PAID <br />0 Cash RE -N iFWED BY <br />❑ Surcharge FEE <br />to <br />Date <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />Date <br />