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SAN JOAQUIN COUNTY OVIRONMENTAL HEALTH DEPAF*ENT� <br />MASTERFILE RECORD INFORMAT16 FORM <br />New EH Program at Existing Facility []New EH Program and New Facility <br />Facility ID IAW9501 Program Record ID -PR ®5'D 1012 <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <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 Ve Ih' I T <br />Registration # <br />ElMobile Food Prep Unit-- Make <br />Registration # <br />ElTemporary Food Facility --Dates of operation from <br />ElSpecial Event ---Dates of operation from <br />ce yp <br />License # _ <br />Vehicle Type <br />License # <br />to <br />to <br />Sticker # <br />_ Color <br />_ Sticker # <br />_ El Ice Plant E] Produce Stand <br />CFO ❑A❑B <br />DAIRY PROGRAM (2000) <br />ElGrade A Dairy ❑ Grade B Dairy ElMilk Dispenser -Number of Containers in Multi -Head Unit_ <br />CUPA <br />1:1Hazardous Materials Business Plan (1900) Number of chemicals: <br />ElCaIARP Program ❑ Program 1 Facility ElProgram 2 Facility ❑ Program 3 Facility <br />Hazardous Waste Generator (2200)----------> Tons Generated Per Year L T- <br />iered Permitting Facility -------> ❑ CA (2232) ElCE (2233, 2234, 2235, 2237) ElPBR (2231) ❑ PBR HHW (2236) <br />ElAboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />ElUnderground Storage Tank Program (UST) (2300) Use UST A and B forms <br />ElOther CUPA Program <br />HOUSING PROGRAM (2400) <br />ElHotel/Motel ------ Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housina/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site 1:1Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ElUIC Site <br />ElAbandoned HW Site Elnon-NPL/SEP Cleanup Site 11RWQCB Cleanup Site 1:1Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility_ ElPool <br />VECTOR CONTROL PROGRAM (4000) <br />ElPoultry Farm -------Maximum number of birds <br />❑ Spa ElOut of Service Pool/Spa 11Natural Bathing Area <br />11Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />ElBody Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ElBody Art Facility -Single Use (4120) <br />ElBody Art Facility -Sterilization (4121) 11Body Art Temp Event Co-ord (4130) ElBody Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />11Pumper Vehicle Registration #. <br />11Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # Capacity Vehicle # <br />El Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />E3Landfill 1:1Transfer Station 13Ag/Cannery Waste Site E3Sludge/Ash Site <br />E3Waste Tire Facility 1:1Compost Facility ElProcess/Recycle Facility 11CIA Landfill Site <br />ElRefuse Vehicles (# of units) 11Dumpsters > 20 cu yd (# of Units) ElFarm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />ElPrimary Care 11Acute Care ElSkilled Nursing ElLarge Generator 11Small Generator ElLimited Hauler <br />ElTransfer Station E]Veterinary Clinic ElCommon Storage Facility IJ2 - 10 1:111 - 60 [J> 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 Day Ph Night Ph <br />PROGRAM ELEMENT <br />ElSurcharge FEE 11Other FEE <br />INSPECTOR# ap0I PERMITVALID t0 <br />1:1Food Handler <br />ElCheck # AMOUNT PAID Date INVOICE # <br />ElCash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />ACCOUNTING OFFICE <br />Zt>l 40 <br />Date <br />PINK <br />