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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT \ <br /> MASTERFILE RECORD INFORMATION FORM <br /> New EH Program at Existing Facility New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Addressrl5��k 30 <br /> (Please check the appropriate description and specify$jig,number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> Restaurant: Seating Capacity Square Footage Food Handlers Machcourines <br /> required: um YES No <br /> Commissary Dry storage only with Food Preparation SIA trending Machine` Number of Units <br /> Retail Market--Square footage)1000 wlMeat Market onty Multiple Departments Prepackaged Goods Ont <br /> Mobile Food Vehicle_.MakQ Vehicle Type _ Color <br /> Registration# License# Sticker# <br /> Mobile Food Prep Unit-Make Vehicle Type Color— <br /> Registration <br /> olor Registration it 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 iJ I i'� <br /> DAIRY PROGRAM(2000) <br /> Grade A Dairy Grade B Dairy Milk Dispenser-Number of Containers in Mufti-Head Unit— N ) <br /> CUPAPE�c�x d Q�cer� <br /> Hazardous Materials Business Plan(1900) Number of chemicals: ke5'A I 0,l_1 owlk Q Q3 e i C z <br /> CaIARP Program Program 1 Facility Program 2 Facility Program 3 Facility <br /> Hazardous Waste Generator(2200)-- >-Tons Generated Per Year t-1 I 4N, <br /> Tiered Permitting Facility > CA(2232) CE(2233,2234,2235,2237) PBR(2231) PBR HHW(2236) <br /> Aboveground Storage Tank Facility(AST)(2800) Number of ASTs 2- <br /> Underground Storage Tank Program(UST)(2300)Use UST A and B forms <br /> Other CUPA Program <br /> ,HOUSING PROGRAM(2400) WA <br /> Hotel/Motel___.Number of Units Jail or Exempt Institution-_Number of Units <br /> Employee Housing(2700)Use Employee Hovsintt2abor Camp Aonlication Form <br /> crTE MITIGATION(2900) UNpERGg0UND IN IECTION CONTROL(3000) <br /> z Environmental Assessment UST-CAP Site Local HW Cleanup Site NPUSEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPUSEP Cleanup Site RWQCB Cleanup Stte Water Quality Remediation Site <br /> gECREATIONAL HEALTH PROGRAM(3600) I <br /> Number of Pools/Spas at FacilityPool Spa Out of Service Pool/Spa Natural Bathing Area <br /> VEC=TOR CONTROL PROGRAM(4000) <br /> Poultry Fam>,__--Maximum number of birds 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 /> r IO 1p WASTE PROGRAM(4200) <br /> Pumper Vehicle Registration# License# Capacity ehide# ^' <br /> Pumper Yard Package Treatment Plant Chemical Toilets--.Number of Units 1" <br /> sni ID WASTE PROGRAM(4400) <br /> Landfill Transfer Station Ag/Cannery Waste Site Sludge/Ash Site t3 <br /> Waste Tire Facility Compost Facility Process/Recycle Facility CIA Landfill Site <br /> � . <br /> Refuse Vehicles(#or unicsl, Dumpsters>20 cu yd(#of Unita) Farm/Ranch Cleanup Site <br /> j1AEDICAL 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 /> ' <br /> PUBUC WATER SYSTEM PROGRAM(4600)Use PWS EHO 46-02-003 Blue Application Farm <br />