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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID Facility Address �c' v � S � ✓' � ��' c` I I S5 C�l S ( 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 : YES ❑ 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 : ❑ CaIARP 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 ) ❑ PER 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 ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (# of Units ) ❑ Dumpsters > 20 cu yd (# of units ) ❑ Farm/ Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500 ) ❑ 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 EHD 46-02- 003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE INSPECTOR # ICT Z PERMIT VALID tO ❑ Food Handler ❑ Check # fqeAMOUNT PAID Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1 /23/13