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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility 60/ ❑New EH Program and New Facility <br /> Facility ID Program Record ID 2�S � <br /> FacilityAddress 16001 r <br /> (Please check the appropriate description and specify size, number of units and Pertinent information,) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle--Make Vehicle Type <br /> Registration# Color <br /> License# Stickerr# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type <br /> Registration# Color <br /> El License# Sticker# <br /> Temporary Food Facility--Dates of operation from to <br /> ElSpecial Event---Dates of operation from ❑ Ice Plant EJ Produce Stand <br /> to ❑ CFD ❑ A ❑ 6 <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ,4 Hazardous Materials Business Plan (1900) Number of chemicals: - <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year <br /> ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use USIA and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Emplovee Housing/Labor Camp Apr,lication Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW 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 Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------Maximum number of birds <br /> ❑ Kennel <br /> TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) <br /> LIQUID WASTE PROGRAM (4200) <br /> Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Purnper Yard ❑ Package Treatment Plant 13Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility 1-1 CIA Landfill Site <br /> Refuse Vehicles(#of units} _ ❑ Dumpsters> 20 cu yd (#or units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> El Primary Care ElAcute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ > <br /> 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS,EHQ 46-02-003 Blue Application Foran <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEM NT U' f FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date <br /> INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 _ — <br /> 1/23113 MASTERFILE R CO INFORMATION FINK <br />