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SAN JOAQUIN COUNTY E RONMENTAL HEALTH DEPARI NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility []New EH Program and New Facility Facility ID �m2s/ID Program Record ID Facility Address (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 ❑ C'Commissary ❑ Dry storage only 10.1kith Food Preparation ❑Vending Machines Number of Units ❑ etail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ET Mobile Food Vehicle--Make Vehicle Type Color Registration# License# t/ Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ElIce Plant ElProduce Stand ElSpecial 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: ❑ CalARP Program ❑ Program 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 Program (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 Event Mobile F4 ity (4131) LIQUID WASTE PROGRAM (4200) PAI IME ❑ Pumper Vehicle Registration# License# Capacity r2 crAWED ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of nits SOLID WASTE PROGRAM (4400) APR 0 3 2 ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Asch. i1;lyTY ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑931 fN ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of Units) ❑ �BAAB7r11��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 EMERGIENcy NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONS a 167 tvI Day Ph 507,,',W7 Z ,Night Ph PROGRAM ELEMENT FEE ❑ surcharge FEE El Other FEE INSPECTOR# - PERMIT VALID to 3 ❑ Food Handler ❑ Check# AMOUNT PAID Date INVOICE# 32-05 _ ash REVIEWED BY ACCOUNTING OFFICE Date 034 MASTERFILE RECOR INF RMATION PINK 1/23/1 1/23/13