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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPAR NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ONew EH Program and New Facility Facility ID Program Record IL, (Please check the appropriate description and FOOD PROGRAM (1600) El Restaurant: Seating Capacity CI Commissary CI Dry storage only CI Retail Market----Square footage 1:3,Mobile Food Vehicle --Make Registration # CI Mobile Food Prep Unit-- Make Registration # CI Temporary Food Facility --Dates of operation from CI Special Event---Dates of operation from Facility Address 40 Square Footage Cl with Food Preparation El w/Meat Market only c_)tic --ci i) e i—ockf specify size, number of units and pertinent information.) Vehicle Type Color License # Sticker # to CI Ice Plant CI Produce Stand to D CFO CIADB Food Handlers Course required: YES NO CI CIVending Machines Number of Units CI Multiple Departments CI Prepackaged Goods Only Vehicle Type Color License # X() '7U Sticker # SAN JOIAritio COUNTY qAR(441Els17AL H DEPARTMENT PAYMEN T RE:CEivED MAR 1 1 2017 El Surcharg FEE to 2- f Date INVOICE # ACCOUNTING OFFICE PROGRAM ELEMENT 4 FEE —2 INSPECTOR # PERMIT VALID ID Check # MOUNT PAID Cash REVIEWED 72--/ CI Other FEE CI Food Handler Date 46V7 DAIRY PROGRAM (2000) Cl Grade A Dairy CUPA ID Grade B Dairy CI Milk Dispenser-Number of Containers in Multi-Head Unit CI Hazardous Materials Business Plan (1900) Number of chemicals CalARP Program CI Program 1 Facility CI Program 2 Facility CI Program 3 Facility El Hazardous Waste Generator (2200) > Tons Generated Per Year CI Tiered Permitting Facility > CI CA (2232) 0 CE (2233, 2234, 2235, 2237) CI PBR (2231) CI PBR HHW (2236) CI Aboveground Storage Tank Facility (AST) (2800) Number of ASTs CI Underground Storage Tank Program (UST) (2300) Use UST A and B forms CI Other CUPA Program HOUSING PROGRAM (2400) CI Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) CI Environmental Assessment CI UST-CAP Site CI Local HW Cleanup Site 0 NPL/SEP Cleanup Site CI UIC Site CI Abandoned HW Site El non-NPLJSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility CI Pool 0 Spa 0 Out of Service Pool/Spa CI Natural Bathing Area VECTOR CONTROL PROGRAM (4000) Poultry Farm Maximum number of birds CI Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) Body Art Practitioner Reg (4110) CI Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) CI Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) CI Body Art-Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) CI Pumper Vehicle Registration # License # Capacity Vehicle # Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) CI Landfill CI Transfer Station El Ag/Cannery Waste Site CI Sludge/Ash Site CI Waste Tire Facility CI Compost Facility CI Process/Recycle Facility CI CIA Landfill Site CI Refuse Vehicles (# of Units) El Dumpsters > 20 Cu yd (# of Units) CI Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) CI Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator CI Small Generator 0 Limited Hauler CI Transfer Station CI Veterinary Clinic CI Common Storage Facility Cl 2 - 10 CI 11 - 60 El > 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 ru..)0(\_ci--,,A, Day Ph ).,d) (-& Night Ph 90 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13