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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION F M ❑ New EH Pro ram at ExIstIn2 Facility New EH Program and New Facility Facility ID �2(�s Pro ram Record ID r� W Facility Address �C g520-�- (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 a 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 Type Color Registration# License# Icker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice /ant❑ Produce Stand ❑ Special Event---Dates of operation from to H-2 a 3 CFO IVA ❑ 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) ❑ PER(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 - 11 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 ❑ NPLISEP 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 EventIeFieoilfii(4131) LIQUID WASTE PROGRAM(4200) IY�1'G"" ❑ Pumper Vehicle Registration# License# Capacity �r ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of UnitASQQ y_ _� �nq^t'� SOLID WASTE PROGRAM (4400) blit ` " ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SISu fOUN f t ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA tlRa NTAL #or units eanup S ❑ Refuse Vehicles ( ) ❑ Dumpsters >20 cu yd (#of units) ❑ FaMd6A'1,�I��I-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 ❑ 2-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM ELEMENT FEE IS IGO ❑ Su ❑rcharg EE ❑ Other FEE INSPECTOR# PERMIT VALID Z t0 Food Handler ❑ heck# AMOUNT PAID Date INVOICE# 2 Cash REVIEWED BY ACCOUNTING OFFICE Date � ,I 2-034 MASTERFILE RECORD INFORMATION PINK 1/23/13