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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Proqram at Existing Facil <br />❑New EH Proqram and New Facil <br />Facility ID A i Lef-0t ±j c � Y �' �<t )j]Cl,­ Program Record ID I <br />Facility Address c -2.O0 -.. <br />(Please check the appropriate description and speci ¢e, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <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 />Food Handlers Course required: YES ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />Color <br />_ Sticker # <br />Color <br />_ Sticker # <br />❑ Ice Plant ❑ Produce Stand <br />KCFO )KA ❑ B <br />DAIRY PROGRAM (2000) <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 />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ----- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility —> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <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 Foran <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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 <br />❑ 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 VehicleRegistration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ Chemical Toilets —Number of Units <br />SOLID WASTE PROGRAM (4400) P <br />❑ Landfill ElTransfer Station ElAg/Cannery Waste Site u ite <br />❑ Waste Tire Facility ❑ Compost Facility ElProcess/Recycle Facility ite <br />❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (# of units)[� Earn/RancCleanup Site <br />Fw <br />MEDICAL WASTE PROGRAM (4500) 2020 <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Sma%eiW <br />9tpk 1:1 Limited Hauler <br />❑ Transfer Station 13 Veterinary Clinic ❑ Common Storage Facility 1:12 -10 �,,'�ME Nb� generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form `PARTj►'E <br />NT <br />CONTACT P <br />PROGRAM ELEMENT <br />Day Pr�r;71aG< <br />❑ Surcharge FEE ❑ Other FEE <br />INNSPPECTOR# PERMIT VALID to <br />Lal Check # 3 31 AMOUNT PAID A5�i Date Z <br />0 Cash REVIEWED BY <br />4&02-034 <br />1/23113 <br />ACCOUNTING OFFICE <br />PF-C)Y+ss31 <br />_ ❑ Food Handler <br />INVOICE # <br />Date <br />MASTERFILE RECORD IN <br />0 <br />TION PINK <br />