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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility Pfw EH Program and New Facility Facility ID Ir 0 :�- 5�1-� j Program Record ID j?. o5 Facility Address .7 3 (- fy�.4 Q Z2 Ln ( 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 ❑ Mobile Food Vehicle --Make Vehicle Type Color Registration # License # 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 ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility Hazardous Waste Generator (2200 )----------> - Tons Generated Per Year S 1�L� /� S , Lt, � �'.(''�-L; � L L L- �❑ 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 USTA 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 Facility (4131 ) 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 (# of units ) ❑ Dumpsters > 20 cu yd (# or Units) ❑ Farm/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 AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT l° FEE a Surcharge FEE r ❑ Other FEE INSPECTOR # ePERMITVALID to p� 11Food Handier 22 1:1Check # AMOUNT PAID Date - l C INVOICE # ✓O J ❑ Cash REVIEWED BY ACCOUNTING OFFICE 1ADate f j9of 48-02-034 MASTERFILE RECORD INFORMATION PINK 1 /23/13