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SAN JOAQUIN COUNTY F (IRONMENTAL HEALTH DEPAR" .NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Zew EH Program and New Facility Facility ID �a i Program Record ID Facility Address 2 3 A 2 (Please check the appropriate description and specify size, number of units and pertinent info ation.) FOOD PROGRA (1600) ElRestaurant: ming Capacity Square Footage Food Hand rs Course required: Yes ❑ No ❑ ❑ Commissary ❑ ry storage only ❑ with Food Preparation ❑Vendin Machines Number of Units ❑ Retail Market----Sq re footage ❑ w/Meat Market only ❑ MultipI epartments ❑ Prepackaged Goods Only ❑ Mobile Food Vehicle- ake Vehicle Type Color Registratl n# License# Sticker# ❑ Mobile Food Prep Unit-- e Vehicle Type Color Registration# License# Sticker# ElTemporary Food Facility --Date of operation from to ❑ Ice Plant ❑ Produce Stand ❑ Special Event---Dates of operation om to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy El Grade B D ❑ Milk 1spenser Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of the als: ❑ CaIARP Program El Program 1 Fa 'lity ❑ Pr gram 2 Facility ❑ Program 3 Facility 11 Hazardous Waste Generator(2200)----------> Tons enerate Per Year �- ^ ❑ Tiered Permitting Facility -------> ❑ CA(2232) CE ( 233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility (AST) (2800) u ber of ASTs El Underground Storage Tank Program (UST) (2300) Use 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 Housin /Labdr Cam A lica 'on 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/SE Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ P of ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of Irds ❑ Kennel TATTOO BODY PIERCING PERMANENT C METIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization (41 1) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Nu er of Units SOLID WASTE PROGRAM (440 ❑ Landfill ransfer Station ❑ Ag/Cannery Waste Site Sludge/Ash Site ❑ Waste Tire Facility Compost Facility ❑ Process/Recycle Facility ❑ A Landfill Site ❑ Refuse Vehicles (#or its) ❑ Dumpsters> 20 cu yd (#or Units) ❑ Fa /Ranch Cleanup Site MEDICAL WASTE PROG AM (4500) ❑ Primary Care Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small GeneratortE160 ited Hauler ❑ Transfer Statio ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 generators PUBLIC WATER SY TEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Fonn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PE SON Day Ph Night Ph PROGRAM ELEMENT.2 FEE I`0 11SurchargeF E 11Other FEE INSPECTOR# IV l A NZ() PERMIT VALID 0 - � to �Z J� )� ❑ Food Handler ❑ Check# AMOUNT PAID_ Date INVOICE# ❑ Cash REVIEWED BYACCOUNTING OF ICE - DateF r -T L 48-02-034 V y ^NJF�TE ,FILE RE DRD NFORMATION PINK 1/23/13 TX( /,{ Imo`J