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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT !I <br /> _ MAS'TERFILE RECORD INFORMATION_FORM <br /> Ne%v EH Progran-i at Existing Facility ❑New EH Program and New Facilr.y <br /> i' Facility ID � �1a1 — --- -- _— <br /> �, Y r _ Procgranl Record ID <br /> Facility Address 7j�lD q/td'1 P/� � p C" <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 ❑ kvith 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 Vehicle Type Color <br /> Registration# License# Sticker# <br /> ElMobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility --Dates of operation from to ElIce Plant 1:3Produce Stand <br /> ❑ Special Event---Dates of operation from _ to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> Wr -Hazardous Materials Business Plan (1900) Number of chemicals <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator (2200)----------= Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA (2232) ❑ CE (2233. 2234. 2235. 2237) ❑ PBR (2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2500) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM ;2400) <br /> ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units _ <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4,131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM (4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles (- Lin;_ ❑ Dumpsters> 20 Cu yd u.,is ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 1 I -60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PVVS EHD 46-02-003 Blue Application Fora) <br /> EF6ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CO'JTACT PERSON Day Ph Night Ph <br /> IPROGRAM ELEMENT FEE U ❑ Surcharge FEE ❑ Other FEE <br /> ' INSPECTOR# OOOU PERMIT VALID to ❑ Food HAl1dICr <br /> � ❑ Check. AMO NT PAID Date INVOICE# <br /> ❑ cash RE;IE,QED 6r -- ACCOO 1CNTINr:,OFFICE--_--_-- Date <br /> L---- ——- <br /> g-r^_r-" 1:1=. TERFILE R <br />