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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F ❑ New EH Program at Existing Facility W<ew EH Program and New Facility Facility ID 1-1-74/1 InDaS d Program Record ID Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) FO D PROGRAM(1600) �� Restaurant: Seating Capacity!'-' !,J Square Footage Food Handlers Course required: YES [I/No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ 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 ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year ❑ 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 Housing/Labor Camp Application 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/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number 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 ❑ SludSite ElWaste Tire Facility ElCompost Facility ElProcess/Recycle Facility 1:1 CI Wnt1Ti� El Refuse Vehicles(#of units) ElDumpsters>20 cu yd (#of Units) ElFa o Site MEDICAL WASTE PROGRAM (4500) /� 11 Primary Care El Acute Care El Skilled Nursing El Large Generator ❑ Small Generatofls orrlt 9 uler El Transfer Station El Veterinary Clinic 11 Common Storage Facility El - 10 El 11 sj,c) >60 h ators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form ENVIRo/V COU EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM � TH DFP ENTAL �c CONTACT PERSON JAp'ti'� o� Day Ph 'O`7 -LZ't-`�'-��'rl Night Ph ?��`I "� E��l PROGRAM ELEMENT FE ❑ Surcph rge FEE ❑ Other FEE INSPECTOR# S7SS� PERMIT VALID t0 t 11 Food Handler ❑ Check# uAMOUNT PAID Date V INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 V MASTERFILE RECORD TN FORMATION PINK 1/23/13