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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Pro ram and New Facilit Facility ID Program Record ID ` Facility Address Psk( � (Please check the appropriate description and specify size, number 6f-nits and pertinent information.) FOOD PROGRAM (1600) 171 Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes [I No El ❑ 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 ❑ I Plant 11 Produce Stand El 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(223 1) ❑ 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 Housinq/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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa El of Service Pool/Spa El Natural Bathing Area VECTOR CONTROL PROGRAM (4000) El 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) 1:1 Pumper Vehicle Registration # License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM (4400) A ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SI ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ Cl El Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Fsr nc toup Site MEDICAL WASTE PROGRAM(4500) £��( ��?� ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Gene t Qj Liml auler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 1iN /R Aerators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form H�EpAR-4 EMERGENCY TIFI ATION FOR THIS FACILITY AND/OR PROGRAM _ ��T CONTACT PERSON c"'> —Day Ph 9_(` 7 PROGRAM ELEMENT,`� �' FEE ❑ Surc arge FEE ❑ Other FEE INSPECTOR# PERMIT VALID I � to I/ 2i ❑ Food Handler ❑ Check# AMOUNT PAID Date /� INVOICE# El Cash 'jj- REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 M STERFILE RECORD INFORMATION PINK 1/23/13