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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ft(New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID 46nProgram Record ID D <br /> Facility Address - S;tTCjM1d7) F­0( <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ etail Market---Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License#$ STT qq Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event--Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ 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 Storage Tank Facility(AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel-----Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ Kennel <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(413 1) <br /> LIQUID WASTE PROGRAM(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA LjMjIQLSite <br /> ._ <br /> El Vehicles(#of units) ❑ Dumpsters>20 cu yd (#of units) ❑ Far /� *�T Site <br /> MEDICAL WASTE PROGRAM (4500) yGtVE/� <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generato, 'rimited FPdMer <br /> ❑ Transfer Station El Veterinary Clinic ❑ Common Storage Facility 1:12-10 ❑ 11 -60 `tY g2O2rtors <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form S%JQ4QUI <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM N �EP�E LINTY <br /> CONTACT PERSON J -1—aj A Day Ph (29!)(0(0'53Lf;a Night Ph 9R <br /> PROGRAM ELEMENT FEE Aj ❑ Surch�a7r e F E 11 Other FEE <br /> INSPECTOR# � PERMIT VALID 2 to ZD ❑ Food Handler <br /> 11 Check# AMOUNT PAID 0f Date 2 2 INVOICE# <br /> LL Cash REVIEWED BY VI� ACCOUNTING OFFICE Date <br /> 48-02-034 MASTERFILE RECORD IWORMATION PINK <br /> 1/23/13 <br />