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SAN JOAQUIN COUNTY E 1RONMENTAL HEALTH DEPAR- 'NT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID T ;L3qfl Program Record ID -O oszL�� J Facility Address M �Wml-) q!J� 0 (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# LS Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# (p 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: ❑ 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-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-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) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units T SOLID WASTE PROGRAM (4400) PA p El Landfill El Transfer Station ❑ Ag/Cannery Waste Site 1:1Sludge/AsMMEjV� ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ny9 El Refuse Vehicles(#of Units) ElDumpsters> 20 cu yd (#of Units) ❑ Farm/Rancf�gteAL� 1,10 MEDICAL WASTE PROGRAM (4500) N COUNTY El Primary Care EI Acute Care El Skilled Nursing El Large Generator 11 Small Generator ❑ LjjfAMENTP�L El Transfer Station El Veterinary Clinic 11 Common Storage Facility El - 10 1:111 -60 El > p6TMENT PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Foran EMERGENCY NOTIFICATION FOR THIS FACILITY AND/O PROGRAM CONTACT PERSONh l U f�Iy Day Ph Night Ph PROGRAM ELEMENT FEE I.*-� ❑ Surchar a FE7 ❑ Other FEE INSPECTOR# PERMIT VALID to ❑ Food Handler ❑ Ch,�cckk-,# °1'3�2v ��MOUNT PAID �1 7?� — Date INVOICE# ❑ CVasn' REVIEWED BY O 5—' - ACCOUNTING OFFICE z-10 Date 7 /` 48-02-034 MASTERFILE RECORD NFO MATION PINK 1/23/13 4 e,j� --#- ✓;(S;