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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID 2 3 Program Record ID Facility Address (Please check the appropriate description and specify size, number of units and pertinent information/) FOOD PROGRAM(1600) / ❑ Restaurant: Seating Capacity Square Footage Food Handlers ourse required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending M chines Number of Units ElRetail Market----Square footage Elw/Meat Market only 11Multiple D artments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ M Dispenser-Number of C ntainers in Multi-Head Unit C PA Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program El Program 1 Facility [],Program `' �a ility ogram 3 Facility ❑ Hazardous Waste Generator(2200)----------> Tons Generated', a ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ C� (2233, 223 ,, 2235, 223 ❑ P (`2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility (AST) (2800 umber of ASTs ❑ Underground Storage Tank Program (UST) (2300) U U T A and B forms �✓ ❑ Other CUPA Program U HOUSING PROGRAM (2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exe t Institution ----Number of Units Employee Housing (2700) Use Em /o ee Housin / o CNication Form SITE MITIGATION (2900) fPROGRAM U INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST- HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-Nte ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility a ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of ❑ Kennel TATTOO BODY PIERCING PERMANENT CO100) ❑ Body Art Practitioner Reg (4110) Mechanical DSPSNotification (4115) El Body Art Facility-Single Use (4120) El Body Art Facility-Sterilization (4121 ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) 11 Pumper Vehicle Registration# // License# Capacity Vehicle# ❑ Pumper Yard 0 Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ 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) ❑ Durnpsters> 20 cu yd (#or 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 ❑ 2- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGE OTIFICATION FOR THIS FACT ITY AND/OR PROGRAM CONTACT PERSON Day Ph fight Ph PROGRAM ELEMENT I9R FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR# _2[1f r PERMIT VALID 1 1I Iq to III?( Iq ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13