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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facilitv 2' New EH Program and New Facilitv Facility ID ),50'% Program Record ID �2�t�l b� Facility Address a (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Restaurant: Seating Capacity Square Footage /- (? Food Handlers Course required: YEs4f�, No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units AORetail 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 ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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 # ❑ Pumper Yard License # ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Waste Tire Facility ❑ Compost Facility ❑ Refuse Vehicles (# of Units) Capacity Vehic' k1- ❑ Chemical Toilets ----Number of Units RECEIVLu ❑ Ag/Cannery Waste Site ❑ Sludge/ 43 �0�9 ElProcess/Recycle Facility El CIA Lan° H S ❑ Dumpsters > 20 cu yd (# of Units) ❑ FarngAWnjt�A81��jq,! tp, MEDICAL WASTE PROGRAM (4500) ENVIRONMENTAL ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator tRg�tR&WATWNT ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON 1 i�1041- , \ ° Day Ph a 31_' -S-(41 -Y6LkNight Ph a�1 r� - S w PROGRAM ELEMENT I P) / -- FEE 15 p ❑ Surcha ge FEE, El Other FEE INSPECTOR� # ' -f � ERMIT VALID ( Z� t0 � ❑ Food Handler AMOUNT PAID S — Date l 3 INVOICE # c3 S ❑ Cash REVIEWED BY ACCOUNTING OFFICE 'rWDate 48-02-034 MASTERFILE RECORD NFCRMATION PINK 1/23/13