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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facili Facility ID Program Record ID Facility Address 9L4da QQ�)d Qy� (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# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility—Dates of operation from to ��-- ❑,,�,, I],,aJJ'''��lant❑ Produce Stand 1:1 Special Event---Dates of operation from to �[1 CFO`�y ❑ 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(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use USTA 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-NPUSEP 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 ArtTemp 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 SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of units) ❑ Farm/Ranch 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 112-10 ❑ 11 -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 Itallt FEE C ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMIT VALID �^^--:l��- t0 ❑ Food Handler ,Check# AMOUNT PAID I✓ Date [5 2 1- INVOICE# Cash lf( REVIEWEDBYCJCSe�— ACCOUNTING OFFICE Date 4/23/13 4„ , I : I �� MASTERFILE RECORD INFORMATION PINK 1/23/13 /I�P',]IY,fVl i