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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM VNe�wE�HProgramatExisting Facility ❑New EH Program and New Facilit Facility ID. GU eVA Program Record ID I Facility Address " U S- (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 Typ. - 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 ❑ 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 EmploVee 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-Sing 9N'T El Body Art Facility-Sterilization (4121) El Body Art Temp Event Co-ord (4130) 11 Body Art-Temp Event'm 131) LIQUID WASTE PROGRAM(4200) RIE ❑ Pumper Vehicle Registration# License# CapacityV�fe#� 1:1 Pumper Yard ❑ Package Treatment Plant El Chemical Toilets----Number of Uni ! lL SOLID WASTE PROGRAM (4400) SAN JOAQUIN COUNTY ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SluclgWAgp NTAL ! El Waste Tire Facility El Compost Facility ❑ Process/Recycle Facility 11Cl��i� tteTMENT ❑ Refuse Vehicles(#of units) ❑ Dumpsters> 20 cu yd (#of 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 NOTI ICATION FOR.THIS FACILITY AND/OR PROGRAM CONTACT PERSON �L�22OI� '� n&1,0 1GIVIA221hl0lI- 'I - 'p5 L Night Phi/Qq g'I'S X 05 Z PROGRAM ELEMENT cJ FEE 7 El 'Surcharge FEE El Other FEE INSPECTOR# PERMIT VALID-/Z [� ZG' to 3/ ❑ Food Handier � ❑ Check# AMOUNT PAID ��" Date 2 'Lo 2,-t-7 INVOICE# f/ 3 I D ❑ sh REVIEWED BY I �� ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13