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L !2t COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑New EH Program at Existin ac It New EH Pro ram and New Faclllt y. Facility ID -2,46-b I program Record ID Facility Address l (Please check the appropriate description and specify size,number of units and pertinent Information J FOOD PROGRAM(1600) ❑ Restaurant Sealing 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# Slicker# ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant[] Produce Stand ❑ Special Event—Dales of operation from to CFO 9(A O B DAIRY PROGRAM(2000) ❑ Grade A Dalry ❑ Grade B Dal CUPA ry 13 Milk Dispenser-Number of Containers in Multi-Head Unit ❑ Hazardous Materials Business Plan(1900) Number or chemicals: ❑ Ca1ARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--->-Tons Generated Per Year ❑ Tiered Permitting Facility---> ❑CA(2232) ❑ CE 12233,2234,2235,2237) ❑ PER(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Taft 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 Remedlation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility _ ❑Pool ❑Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM m nu pAV NtG ❑ Poultry Farm----Maximum number of birds f^I z,�G+lzr' TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) REC ❑ Body Art Practitioner Reg(4110) 13 Mechanical DSPS Notification(4115) ❑ Body Art Fa�r,I I Ie,I`srr1(4120) ❑ Body Art Facility-StefAintlon(4121) ❑Body Art Temp Event Co-ord(4130) ❑ Body Art-�Ki E NTODRe Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper VehlcleRegistration# License# Capacity SAN JOAQUIN COUNTY ❑ Pumper Yard ❑ Package Treatment Plant [I Chemical Toilets-- �f� (TMENI SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site IJ SludgelAsh Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of unes) ❑ Dumpsters>20 cu yd(#of Un,N) _ ❑ 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 O 2-10 ❑ 11-60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form R ENCY OTIFICATION FOR THIS FACILITY AND/OR PROGRAM f�� p// CONTACT PERSO Day Ph Night Ph2�'�—O`+zq PROGRAM ELEMENT FEE ❑ Sure rgeF ❑ Other FEE El oR# 'JP0UNT A11) Dae— ❑ Food Ha d�leTr� 0 �� 3 h(OUNTPAID � Date ) INVOICE# ❑ Cash REVIEWED DY ACCOUNTING OFF ICE M,4 Date 48-02-034 IASTERFILE RECORD INFORMATION PINK L112])13