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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION ORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID Q�,Z(oJ Program Record ID o d Facility Address (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 u) 1116 Registration# License# I)b Sticker# R 03D40114 ❑ 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) ❑ PER 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 ❑ NPUSEP 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..Maximumnumber 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) El Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM (4200) PAYMENT ❑ Pumper Vehicle Registration# License# Capacity �[1([eS{t��fe ^ ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number V C>tl� SOLID WASTE PROGRAM(4400) /A� n { gOZt El Landfill El Transfer Station ElAg/Cannery Waste Site ❑e ge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ,�Aptl TY 11 Refuse Vehicles )#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑N'Y up Site MEDICAL WASTE PROGRAM (4500) HEALT ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form n (y� GENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Qy t7 [/ ECIC Day Phy8 a?�?iq Night Ph PROGRAM ELEMENT FEE ❑ Su c ge FEE ❑ Other FEE INSPECTOR# PERMIT VALID Z to�3I Zo20 ❑ Food Handler ❑ heck# AMOUNT PAID Date INVOICE# Cash REVIEWED BY ACCOUNTING OFFICE Date 8-02-034 MASTERFILE RECORD It4FORMATION PINK 1/23/13