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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Fpr aaloI -�2. Program Record ID /nnWS . Facility Address 0 S •C l i �G (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 ❑ tail Market ----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only Mobile Food Vehicle --Make Vehicle Type Color Registration # License # '� '1 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 ❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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 TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ 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 Event Mobile F1,j4ty,(��3.1 T LIQUID WASTE PROGRAM (4200) 1'ATMC ❑ Pumper Vehicle Registration # License # Capacity Vehicle # RECEIVED ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units 2��9 SOLID WASTE PROGRAM (4400) APR 12 ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/As20AQUIN COUNTY ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill %WIRONMENTAL ElRefuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) ElFarm/RancH@%- WMTMENT 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 CONTACT PERSOPAINLAY' N 1 PROGRAM EL INSPECTOR # ❑V��"� ❑ Cash 48-02-034 1/23/13 Day Ph :MENT FEE ❑ Surcharge FE PERMIT VALID to r' Z 3 00(a �_3ZAMOUNT PAID 'z °j �— — Date L i Night Ph i ❑ Other FEE ❑ Food Handier INVOICE # _y REVIEWED BY ACCOUNTING OFFICE Date 'l14�11 MASTERFILE R INFORMATION PINK