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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ew EH Program and New Facility Facility ID Program Record ID Facility Address r a ✓,, vn<Fi adrr �-4 95,31/ (Please check the appropriate description and specify Size, number of units and Dertinent 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 �Z ❑ lce Rlant❑ Produce Stand ❑ Special Event—Dates of operation from to ®'CFO b A ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Mufti-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 ❑ 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 ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP 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 Coord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehicleRegistration# 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 She ❑ Refuse Vehicles I#of Unft) ❑ Dumpsters>20 cu yd (#of Units) ❑&ym/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) NjW 13Primary Care ❑ Acute Care 13Skilled Nursing ❑ Large Generator 13Small GenfHauler 13 Transfer Transfer Station ❑ Veterinary Clinic Common Storage Facility 13132-10 11 -(g0 enerators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.62-003 Blue Application Form 0 r Q 2 1020 EMERGENCY NOTIFICATION FOR H FACILITY AND/OR PROGRAM SAV JDgQ CONTACT PERSON U/H CO PROGRAM ELEMENT FEE J ❑ Surcharge FEE ❑ Other t-1MEuT INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Check# AMOUNT PAIDof Date o d. INVOICE# . ❑ Cash REVIEWED BY ACCOUNTING OFFICE 0 JAW Date 48-02-034 ' ILF�1�O � - V MASTERFILE RECORD INFORMATION PINK 1/23/13