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SAN JOAQUIN COUNTY 4VIRONMENTAL HEALTH DEPAK . .JIENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID dC7ZZ?7 Program Record ID y//lDs3 j'$f Facility Address D- (Please check the appropriate description and specify size, number of uand pertinent information.) FOOD PROGRAM (1600) �j ❑ 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# 2 Mobile Food Prep Unit--Make CS M(i— Veliicle Type Color Registration#S�5 l)?4�i _W.1 n 17a',Cense# 1 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) ❑ 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) Q/\�MAN TI�r 1:1 Primary Care El Acute Care ❑ Skilled Nursing El Large Generator El Small Generator C El Transfer Station E) Veterinary Clinic El Common Storage Facility El - 10 1111 - 6o RIECE)YEtors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form FEB0 2 2015 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM =fit , CONTACT PERSON vn 5 i y\n �-g 2 Gr"� C�, t Day Ph � �� q � �;,��j Night Ph SAN JOAQUIN COUNTY PROGRAM ELEMENT I FEE �) �`� ❑ Surcharge F E ElOtheTH Ff;kTH DEPARTMENT INSPECTOR# PERMITVAUD to �5 _ ❑ Food Handler__ ❑ Check# AMOUNTPAID Date o2 t INVOICE# 35� [�'Cash REVIEWED BY ACCOUNTING OFFICE Date 3 1s 48-02-034 MASTERFILE RECO .D INFORMATION PINK 101/111