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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility bNew EH Program and New Facility <br /> [Facility ID Program Record ID 11 <br /> Facility Address r'c% � - oo S � L ; .� � c , G, � / r� Jhoc ic� �i S ��' <br /> ( Please check the appropriate description and specify size , ' riumber 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 Vehicle Type Color <br /> Registration # License # Sticker # <br /> ❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br /> Registration # License # Sticker # <br /> ❑ Temporary Food Facility -- Dates of operation from to ❑ Ice Plant ❑ Produce 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 /> '.,Hazardous Materials Business Plan ( 1900 ) Number of chemicals : <br /> ❑ CaIARP 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) (2800) 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 - NPUSEP 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 (4131 ) <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 (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ 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 ❑ 11 - 60 ❑ > 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 �� ZC`� FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR # PERMIT VALID to ❑ Food Handler <br /> ❑ Check # AMOUNT PAID Date INVOICE $� <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD INFORMATION PINK <br /> 1 /23/13 <br />