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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existing Facility New EH Program and New Facility <br />Facility ID <br />Facility Address <br />o� 4 C� l l o t:J `� <br />Record ID <br />�.�z iS-- <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 />❑ Retail Market ----Square footage ❑ w/Meat Market only ❑Multiple Departments ❑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 ❑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 />CUP <br />azardous Materials Business Plan (1900) Number of chemicals: <br />❑ CaIARP Program ❑Program 1 Facility ❑Program 2 Facility <br />❑ Hazardous Waste Generator (2200) ---------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑PBR HHW (2236) <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-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br />❑ 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 (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper VehicleRegistration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ 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 Landfill Site <br />❑ Refuse Vehicles (# or units) ❑ Dumpsters > 20 cu yd (# or units) ❑Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑Acute Care ❑Skilled Nursing ❑Large Generator ❑Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑Veterinary Clinic ❑Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Applicafion Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON Day Ph Night Ph <br />PROGRAM <br />ELEMENT � i Z FEE <br />❑Surcharge FEE <br />❑Other FEE <br />INSPECTOR <br /># �� Z PERMIT VALID <br />to <br />❑Food Handler <br />❑ Check # <br />AMOUNT PAID <br />Date <br />INVOICE # <br />❑ Cash <br />REVIEWED BY <br />ACCOUNTING OFFICE <br />Date <br />423-UL-U:f4 MASTERFILE RECORD INFORMATION PINK <br />1/23/13 <br />