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SAN JOAQUIN COUNTY EONMENTAL HEALTH DEPARTI&T MASTERFILE ORD INFORMATION FORM New EH Proaram at Fxistina Facilitv ❑New EH Proaram and New Facilitv Facility ID E —D'&0% 6$ Program Record ID Facility Address ::2 - c�� (Please check the appropriate description and specify size, number of units and o rtinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity_ Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ 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 --Make Vehicle Type Color Registration # ❑ Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from DAIRY PROGRAM (2000) License # _ Vehicle Type License # to to Sticker # Color _ Sticker # _ 11 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: alARP Program 11 Program 1 Facility EI Program 2 Facility ❑ Program 3 Facility Hazardous Waste Generator (2200)----------> Tons Generated Per YearX.5 ❑ 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 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ 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 # ❑ Pumper Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ 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 1:12 - 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 �J Day Ph Night Ph PROGRAM ELEM NT -2- FEE ❑ Surcharge FEE ❑ Other FEE INSPECTORPERMIT VALID to ❑Food Handler ❑ Check # ❑ Cash 48-02-034 1/23/13 AMOUNT PAID REVIEWED BY ACCOUNTING OFFICE INVOICE # Date ` PINK