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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Pr Failt Iam at Exsistin Facility ❑New EH Program and New Facility Pro ram Record ID �� D Facility Address MIA (Please check the appropriate description and specify size,number of units and pertinent information) FOOD PROGR4h(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 M_u(iiple Departments 11 Prepackaged Goods Only C1 Mobile Food Vehicle--Make. (�( Vehicle Type Y1 Color Registration#_ v License# Sticker# O'Mobiie 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 8 Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan X1900) Number of chemicals ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)------> Tons Generated Per Year Al ❑ Tiered Permitting Facility----> CA(2232) CE(2233,2234,2235,2237) ❑ PBR(223 1) PBR 11 Aboveground Cctl Aboveground Storage Tank Facility(AST)(2800) Number of ASTs C 1311El 11 Underground �C® Underground Storage Tank Program (UST)(2300) Use UST A and B forms 11APR A Other CUPA Program ,® 20 HOUSING PROGRAM(2400) S ?® ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution---Number of .AQI rig, Employee Housing (2700)Use_Employee Housing/Labor Camp Application Form HEALTH ONIi1 UIVTy SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) �`PARTMENT ❑ Environmental Assessment ElUST-CAPSite El Local HW Cleanup Site [INPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLJSEP 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 Facility(413 1) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# _ Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets---Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles is of Units) ❑ Dumpsters>20 cu yd(if of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing El Large Generator ❑ Small Generator El 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 ME NCY NOTIF CATION FOR THIS FACI TY ND/OR PROGRAM CONTACT PERSON ii Gay Ph ht P 1 PROGRAM ELEMENT FEET �3', � ❑ Surcharg FEE ❑ Other FEE INSPECTOR# PERMIT VALID t0 d zD C3 Food Handler ❑ Check# AMOUNT PAID - 37. 6 c� Dated INVOICE# Z ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 7�f��Zg MASTERFILE Rt COAD INFORMATION PINK 48-02.034 / o 1/23/13