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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Pro, Facility ID ,--&O,�2.337 (o Program Record ID S Facility Address (,l1 (Please check the appropriate description and specify size, number of units and p FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage Fo, ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑� ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ M ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit-- Make Vehicle Type Registration # License # ❑ Temporary Food Facility --Dates of operation from to ❑ Special Event ---Dates of operation from to TMENT and New Facil Handlers Course required: YES ❑ No ❑ nding Machines Number of Units iple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # ❑ Ice Plant ❑ Produce Stand El 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: CalARP Program ❑ Program 1 Facility ❑ Program 2 acility ❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2: ❑ 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 Exen Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION COP ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Clear RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of VECTOR CONTROL PROGRAM (4000) ❑ 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 -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # C ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemic SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Si ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Fac ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generato ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicatic EMERGENCY NOTIFICATION FOR THIS FACILITY ANC CONTACT PERSON PROGRAM ELEMENT INSPECTOR # ❑ Check #_ ❑ Cash 48-02-034 1/23/13 =(_ FEE_ _ PERMIT VALID AMOUNT PAID REVIEWED BY Day Ph ❑ Surcharge t0 Date ACCOUNTING OFFICE ❑ Program 3 Facility 7) ❑ PBR (2231) ❑ PBR HHW (2236) pt Institution ----Number of Units ROL (3000) ❑ NPL/SEP Cleanup Site ❑ UIC Site p Site ❑ Water Quality Remediation Site rvice Pool/Spa ❑ Natural Bathing Area ❑ Kennel ❑ Body Art Facility -Single Use (4120) ❑ Body Art -Temp Event Mobile Facility (4131) apacity Vehicle # al Toilets ----Number of Units ❑ Sludge/Ash Site ity ❑ CIA Landfill Site of Units) ❑ Fann/Ranch Cleanup Site ❑ Small Generator ❑ Limited Hauler 1 2 - 10 ❑ 11 - 60 ❑ > 60 generators 7 Fonn AM Night Ph ❑ Other FEE ❑ Food Handler INVOICE # Date MASTERFILE RECORD INFORMATION PINK