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SAN• JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facilit New EH Program and New Facility <br /> Facility ID F QO Program Record ID Z <br /> Facility Address 617520-3 <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 /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE (2233,2234, 2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) <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 /> 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-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site _ <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ 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 Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ 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 I#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ FaftRanch Cleanup Site <br /> MEDICAL WASTE PROGRAM (4500) M <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generaauler <br /> El Transfer Station ❑ Veterinary Clinic El Common Storage Facility EI2- 10 1111 -6o El > 6 ators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form OpA���M-14r � U Im <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM �'�/rJ <br /> CONTACT PERSON bt. Z Day Ph( ) 373��i��' Nigh �f►OftjjNCo <br /> PROGRAM ELEMENT FEE (/ ❑ Surcha ge FEE ❑ Other FEE Ar? <br /> INSPECTOR# PERMITVALID t0 1 ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date t <br /> flW12-i INVOICE# &S 2A10S <br /> ❑ Cash A I, REVIEWED BYr ACCOUNTING OFFICE Date s/� <br /> 4123113 4 „ _ /�f�-, . 12-5 I MASTERFILE RECOR INFORMATION PINK <br /> 1/23/13 /l'�C/17ypU_V'l�r' <br />