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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New F_i I Program at Existing Facility ❑New FH Program and New Facility -- - -- Facilit ID Program Record ID Facility Address I0/A F tn, (Please check the appropriate description and specify size, number of units and pertinent information.) t: =, FOOD PROGRAM (1600) I, ❑ Restaurant: Seating Capacity Square Footage - Food Handlers Course required: Yes ❑ NO .1 ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ MUltiple Department Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color s Registration # !. License tl 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 'n DAIRY PROGRAM (2000) 1 El Grade A Dalry 1:1 Grade B Dairy E3 Milk Dispenser-Number of Containers In MUlti-Head Unit CUPA Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program 11 Program 1 Facility El Program 2 Facility ❑ Program 3 Facility L ❑ Hazardous Waste Generator (2200)----------> ,Tons Genemted'Per Year R- ❑ .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 HousinalLabor Carne Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site IDUIC Site El Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Nurnber of Pools/Spas at Facility ❑ Pool ❑ spa ❑ Out of Service Pool/Spa ❑ "Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry 'Farm ------- Maximum number of birds ❑ 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 # _ -Capacity Vehicle #' ❑ Pumper Yard ❑ 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) - ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) El 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 END 46-02-003 Blue Application Fonn EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON'Aflow, Day Ph 2A Night Ph PROGRAM ELEMENT FEE ,2, o ❑ Surcharc e/FEE El Other FEE _ INSPECTOR # PERMIT VALID to ❑ Food Handler T ❑ Check i/- AMOUNT PAID Date_ i INVOICE # c El Cash REVIEWED BY ACCOUNTING OFFICE r� Date _- V23113 jj ! �� tMASTERFIL.E RECORD'INFORMATION PINK a.� ir,��u��a�ssasr - a#k%ni�r�si�;d.l��PJT14� I/