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SAN JOAQUIN COUNTY Ef ZONMENTAL HEALTH DEPARTf JT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Prograrn and New Facility Facility IDT 71A�.2.Sc Program Record IU_ G� Facility Address S CA it 10 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ 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 t4'Mobile Food Vehicle--Make Vehicle Type Color Registration# License# 4PPES—d-31 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 ❑ Prograrn 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 Prograrn (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 Ever 9ity (4131) LIQUID WASTE PROGRAM (4200) �� ❑ Pumper Vehicle Registration# License# Capacity E� I G ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of 1,1,tA SOLID WASTE PROGRAM (4400) JU'�l ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site qANjjd00AftTY ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ cAM19 L �� ENT El Refuse Vehicles mor units) ElDumpsters> 20 cu yd (#or Units) EJF arm/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 AN /OR ROGRAM p Q �f CONTACT PERSON MtAKW A "1-Q2re-eS Day Ph fight Ph 0 $1 PROGRAM ELEMENT1i�03 FEE ❑ Surcharge FEE El Other FEE INSPECTOR# �.9� ( PERMIT VALID' t0 ( / ❑ Food Handler ❑ Check# J4 AMOUNT PAID Date INVOICE# 3Z377/ Cash REVIEWED BY ACCOUNTING OFFICE Date 7/; 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 q-1