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r <br />.SAN JOAQUIN COUNTY E` 'RONMENTAL HEALTH DEPART 'NT PAYIWE <br />MASTERFILE RECORD INFORMATION FORM ReC�,VED <br />ew EH Program at Existing Facility New EH Program and New Facility AUG 10 <br />2015 <br />Facility ID FA0028,273 Program Record ID �03 d SAN JOAQUIN <br />ry�1WE ( rOM N <br />'k CALHNOUel���ress ����ELHOPa WAL <br />(Pasetheck the appropriate description and specify size, of and information.) <br />r <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 Color <br />Registration # License # Sticker # <br />❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # Sticker # <br />❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to []CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP 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, 22 7) ❑ PBR (2231) ❑ PBR HHW (2236) <br />.Aboveground Storage Tank Facility (AST) (2800) Number of ASTs � '� a.0 10k } <br />❑ Underground Storage Tank Program (UST) (2300) Use UST Aand Bforms // <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 Employee Housing/Labor Camp Application 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-NPL/SEP 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 />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <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 # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400 <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets -----Number of Units <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd I# of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 62<�1.3LV_- n-) NL rjANi�;l? Day Ph SI0 i 3O 55-Z Night Ph SIU 8 3c� s�a3 <br />PROGRAM ELEMENT C�-Y �N FEE C7 <br />INSPECTOR # PERMIT VALID <br />❑ Check # AMOUNT PAID <br />Cash REVIEWED BY <br />4 -02-034 <br />1 3/13 <br />(U 0 Surcharge FEE c35 <br />0 <br />Date g b <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE# ouo/d3 <br />Date <br />MASTERFILE RECORD INFORMATION PINK <br />