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I <br /> SAN JOAQUIN COUNT El IRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE CORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ( New EH Program and New Facility <br /> Facility ID - ;21"-- Program Record ID -2 ' <br /> 11 <br /> Facility Address2150 )LI 9.5,377 <br /> (Please check the appropriate description and specify size, number o units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only2 with Food Preparation ❑Vending Machines Number of Units <br /> f� Retail Market----Square footage > ❑ w/Meat Market only ❑ Multiple Departments Ia 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 opE -ation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event—Dates of operatio i from to [] CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Gr de B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business F Ian(1 00) Number of chemicals: <br /> ❑ CalARP Program Proo am 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(22)0)---- ----->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility------ ❑ fA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Fac lity(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Proc ram (I.ST)(2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel--Number of Units — El Jail or Exempt Institution----Number of Units <br /> Employee Housing(2700) Use Em to ee HcousinqlLabor 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 ❑ rion-NIILJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM( 600) <br /> Number of Pools/Spas at Facility Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> El Poultry Farm-----Maximum num er ofirds ❑ Kennel <br /> TATTOO BODY PIERCING PERM ANE COS ETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4 21) D 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 E PacKage Treatment Plant ❑ Chemical Toilets----Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transf r StafiDn ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Comp t Fac i lity ❑ 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 E. 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(4 00) e PWS EHD 46-02-003 Blue Application Form <br /> MERG Ncy-NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON.,r Day Ph 2'P ight Ph <br /> PROGRAM ELEMENT FEE D2) ❑ Surchar /FE El Other FEE <br /> INSPECTOR# TSx f PERM VAL t0 ( 2,Q ❑ Food Handler G <br /> ❑ Check# 1/,�s�. AMOUN PAI Date � <br /> INVOICE# ! <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 48-02-034 /� ,� MASTERFILE RECORD J FO NATION PIN.K <br /> �/- <br /> 1/23/13 fJ���l",llrr��//TT//••// <br />