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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN MASTERFILE RECORD INFORMATION FORM T ❑ New EH Pro ram at Existing Fa 'lit Facilit !D D ❑New EH Pro ram and New Facility Program Rec rd ID Facility Address I � (Please check the appropriate description and specify size, number of units and � i ertinent infor ation.) FOOD PROGRAM(9600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ---- Food Handlers Course required: Yes ❑ No Elg Y ❑ with Food Preparation El Retail Market----Square footage ,El Machines Number of Units ❑ Mobile Food Vehicle--Make ❑ w/Meat Market only Multiple Departments❑ Prepackaged Goods Only Type �,�.�% Registration# Vehicle TColor ❑ Mobile Food Prep Unit--Make License# Sticker# Registration# Vehicle Type Color License# ❑ Temporary Food Facility --Dates of operation from Sticker# ❑ Special Event---Dates of operation from to ❑ Ice Plant❑ Produce Stand to El CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dai CUPA ry 13 Milk Dispenser-Number of Containers in Mufti-Head Unit ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PEIR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ derground Storage TO Program (UST) (2300 Use U A and B forms )4-Mer CUPA Program HOUSING PROGRAM(2400) E1 Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee-Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas 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) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) 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 ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#or units) ❑ Dumpsters>20 cu yd (#of units) ❑ FarmlRanch 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THis FACILITY AND/OR PROGRAM CONTACT PERSON r�'d Day Ph Night Ph PROGRAM ELE�MJET FEE o�[o! Surcharge FEE Other FEE �S INSPECTOR# t/V PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# a/ qoZ ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date ' Z/ ^ 48-02-034 MASTERFILE RECORD INFORMATION PINK 1123/13 ( 6