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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM 'New EH Program at Existing Facility ❑Mew EH Program and New Facility Facility ID - "v� Program Record ID Facility Address t ?:� Oc �� -� �� Z�Cs� � q S2_-�-4 (Please check the appropriate description and specify size, number oi units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity ,Square Footage Food Handlers Course required: YES No ❑ ❑Commissary El Dry storage only with Food Preparation ❑Vending Machines Number of Units El 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) ❑ 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 Housinq/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) 4� ❑ Body Art Facility-Sterilization (4121) ElBody Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Fac (413 �f/�►� LIQUID WASTE PROGRAM (4200) S !�' ElPumper Vehicle Registration# License# Capacity Vehiclel gam__ zij 0�o ❑ Pumper Yard ❑ Package Treatment Plant ElChemical Toilets----Number of Units h iR 1N O SOLID WASTE PROGRAM (4400) DFpq 4T <N7 ' ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site MFNT ❑ 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 (��7 �i 1�G�i �'� i� L l f2 Day Ph �Oq— �j.�_S77SNight Ph PROGRAM ELEMENT I FEE ' ' ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID I I �L I ZD to t �I 1.2-1 ❑ Food Handler ❑ Check# 354-' AMOUNT PAID o2- —7 • Date I '-4 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 117ii7r. c7 48-02-034 MASTERFILE RECORID INFORMATION PINK 1/23/13