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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility [I New EH Program�aznLdNew Facility Facilit ID ODZ(,b�2 Program Record ID AD 6 /to 11 Facility Address U CCO�t (Please check the appropriate description and specify size, umber 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 I5�-Plant❑ Produce Stand ❑ Special Event---Dates of operation from to tkCFO 0 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-NPLISEP 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 Evegt WM*jlity(4131) LIQUID WASTE PROGRAM (4200) Y;7F �^ Ell Pumper Vehicle Registration# License# Capacity R� V ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Unit�s� n 7 SOLID WASTE PROGRAM (4400) A UNTY ❑ Landfill 11 Transfer Station ❑ Ag/Cannery Waste Site ❑ MFb*WW)11XC:1eanup � ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ ENT ❑ Refuse Vehicles I#or units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Site MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112- 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 6flegrOK OD Q. Day Ph Night Ph PROGRAM ELEMENT FEE 11Surchar FEE El Other FEE INSPECTOR# (l PERMITVALID g1 2AZ6 t0 ❑ Food Handler ❑ Check# CQeJI I AMOUNT PAID Date b Ll� INVOICE# El Cash REVIEWED BY Loll k t/l ACCOUNTING OFFICE Date *W2- 48-02-034 �� MASTERFILE RECORD INFORMATION PINK 1/23/13