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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existing Fa <br />Facilitv ID <br />Facility Address c;—/O(, tS cd I F clt <br />(Please check the appropriate description and specify <br />FOOD PROGRAM (1600) <br />❑New EH <br />Program Record ID <br />m and New Facil <br />number of units and pertinent information.) <br />❑ Restaurant: Seating CapacitySquare Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ---Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Registration # License #_ <br />❑ Mobile Food Prep Unit— Make Vehicle Type <br />Registration # License #_ <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event --Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />Color <br />Sticker # <br />Color <br />Sticker # <br />to ❑ Ice Plant ❑ Produce Stand <br />PTCFO P(A ❑ B <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200Y -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility ----- -> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution --Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor 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 ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm ----Maximum number of birds ❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ 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 ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) A*ite El Landfill El Transfer Station ❑ Ag/Cannery Waste Site Site <br />ElWaste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility <br />❑ Refuse Vehicles p of Units) ❑ Dumpsters > 20 cu yd (# of Units) 0 Farm/Ranc Cleanup Site <br />MEDICAL WASTE PROGRAM (4500)��►� <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Sm OW ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10QM 1 M�,I eft generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form PARNT <br />CONTACT <br />PROGRAM ELEMENT FEE <br />INSPECTOR # J &" PERMIT VALI <br />❑ Check# 33�f AMOUNT PAID <br />❑ Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />Day P <br />❑ Surcharae F E <br />to 'i`.: 7 <br />I--- Date <br />ACCOUNTING OFFICE <br />LL4-t- Night Ptt( C C% ),f,? - % 484- <br />❑ Other FEE <br />❑ Food Handler <br />INVOICE # <br />Date / 2�' <br />MASTERFILE RECOR IN ORMATION PINK <br />