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,s,AN JOAQ AN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at E)dsting Facility 2Wew EH Program and New Facility <br /> Facil" ID f4cow, Record ID <br /> Facility Address /5a06- <br /> (Please check the appropriate description and specify sitz number of units saw pertirrerrt ir fan ) <br /> FOOD PROGRAM(1500) <br /> ❑ Restaurant: Seating Capacity SquareFootage Food Handlers Course required: YEs❑ NO ❑ <br /> ❑wry ❑ Dry awagL Only 0 vAth Food Pmparation ElVending Machines Number of Units <br /> ❑Retail Market-Square footage ❑wRilleat LUrket only E3 Multiple Deparhmnts C] Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit-Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility-Dates of operation from to fee ❑Produce Stand <br /> EI Special Event-Dates of operation from to CFOA EB <br /> DAIRY PROGRAM(2000) <br /> ❑ Grade A Dairy ❑ Grate B Dairy ❑Milk Dispenser-Number of Cars in Mu6Head Unit _ <br /> CUPA <br /> ❑ Hazardous Materials Business Plan(1900) Number of chemicals: <br /> CaIARP Program D Program 1 Fxitit r ❑Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)— >-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility—> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storm Tm k Facility(AST)(2800) Number of ASTS <br /> ❑ Underground Storage Tank Program(UST)(2300)Use USTA and 8 harms <br /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ HOteIMObeI—Number of Units 0 Jail or Exempt Institution—Number of Units <br /> Employee Housing(2700)Use Employee Wo-u—s lLabor Camp Application Form <br /> SITE MMGATM(2900) UNDERGROUND INJECTION CONTROL(3DOD) <br /> ❑Environmental Assessment 0 UST-CAP She CI Local HW Cleamgr Site EI NPUSEP Cleanup Site ❑ UIC sue <br /> ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑RWOCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of PoolslSpas at Facility _ 0 Pool ❑ Spa ❑Out of Service PooVSpa ❑ Haburat Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ Kennel <br /> TATTOO,BODY PIERCINIM PQiMANENT COSMETIC PROGRAM(4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑Mechanical.DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Fon(4121) D Body Art Temp Event Co-ord(4130) D Body Art-Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper VehicieRegistration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment PWrR ❑ Chemical Toilets--Number of UnRAlf E <br /> SOLID WASTE PROGRAM(4400) RECEIVED <br /> ❑ Landfill El Transfer Station ❑Ag/Cannery Waste Site D Sludge/Ash Site <br /> ❑ Waste T-ve Facility EI Compost Facility ❑PiroossmRacycle Facility 11 CIA QVIfill!M320 <br /> ❑Refuse Vehicles(#of unit) ❑Dumpsters>20 cu yd(#munft) ❑Fatm/Ranch RM"Ite <br /> MEDICAL WASTE PROGRAM(4500) SAN JOAQUI <br /> ❑ Prima Care ❑Aare Care ❑Skilled <br /> ENVIRONMENTAL <br /> Primary Nursing ❑Larks ❑smati Gt �1}i1�8R;�W <br /> ❑ Transfer Stadion ❑Veterinary Clinic ❑ Common Storage Facility ❑2-10 011-60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> blO FoRTHLsFACILITY ANo/oRPROGRAM <br /> �CONTACTPERSON R -Day Ph ht Ph <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR III PERMITVALID t0 ❑ Food Handler <br /> ❑ oh�ok LAMOUNT PAID ($� Date L/ 40 '1-0 VOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICEDate <br /> 4802-034 MASTERFILE RECORD INFORMATION PINK <br /> 1/23/13 <br />