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SAN JOAQUIN COUNTY EOIRONMENTAL HEALTH DEPAR NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility NNew EH Pro ram and New Facility Fac ilitID ` . ,A r/FEProgram Record ID Facility Address LD L2 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) 11 Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: Yes 11 No 1:1 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--MakeVehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA [Hazardous Materials Business Plan (1900) Number of chemicals: [I CaIARP Program El Program 1 Facility 11 Program 2 Facility 11 Program 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA(2232) ❑ CE(2233, 2234, 2235, 2237) ❑ PBR(2231) ❑ PER 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) ❑ El 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 ❑ 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) ❑ Kennel ❑ Poultry Farm-------Maximum number of birds 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) Capacity Vehicle# ❑ Pumper Vehicle Registration# License# P Y ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) 11 Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site 11SludgelAsh Site El Waste Tire Facility [I compost Facility ❑ Process/Recycle Facility 11 CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd I#of 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- 10 011 -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—L-1-1-1FEE ) ( OLti ❑ Surcharge FEE ❑ Other FEE INSPECTOR# I PERMIT VALID t0 El Food Handler ❑ Check# AMOUNT PAID Date INVOICE# �] ^ ACCOUNTING OFFICES Date ❑ Cash REVIEWED BY (/!'' 1 MASTERFILE RECORD INFORMATION PINK 48-02-034 1/23113