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SAN JOAQUIN COUNTY EN' 0NUILNTAL HEALTH DEPARTIV IT MASTERFILE RECORD INFORMATION FORM New EH Proaram at Existina Facilitv []New EH Proaram and New Facilit% Facilitv ID i �.2 Proaram Record ID Facility Address JL`t6 uG�-&"cl IV[Art' (Please check the appropriate description ands ecify size, n tuber of units FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type_ Registration # License # ❑ Mobile Food Prep Unit-- Make Vehicle Type _ Registration # License # _ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) and Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand ❑CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ®'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) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use EmploVee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP 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 I# of Units) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch 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 Day Ph Night Ph PROGRAM ELEMENT I % 2--1 FEE fie— 13Other FEE INSPECTOR # ow t7 PERMIT VALID to ❑ Food Handlerz ElCheck # AMOUNT PAID j �,C Date -7l1 D S - INVOICE # 4rl✓07/L ❑ Cash REVIEWED BY �%GJ-/J,,,eA f'jJ ACCOUNTING OFFICE ( Date %//Dh S- 1/231334 ��1��` 0� RFILE�ECO