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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Prooram at <br />ram Record ID <br />Facility Address 11 Z�7 <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 />❑ etail Market --Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />dgehicle -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 -- Q ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to q/ CFO X A ❑ B <br />DAIRY PROGRAM (2000) V` <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 <br />❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility ------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use USTA and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel---Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housinp/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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <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 F I 'tµ AT) <br />LIQUID WASTE PROGRAM (4200) PA` <br />❑ Pumper VehicleRegistration # License # Capacity VehiIReceill <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) MAI -t- n" <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash J Sit UN COUNTY <br />11 Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑CIA LpNMENTAL <br />❑ Refuse Vehicles (# of UTI ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/RAgbq <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT <br />Til <br />IE"r/_IL'�f� <br />PROGRAM ELEMENTU V JjV b FEE th ElSurcharge F 13 Other FEE <br />INSPECTOR# 1�� p PERMIT VALID J -Z t0 S ❑ Food Handler <br />heck #Ill 9 AMO NT PAID Date AINVOICE # 3 <br />Cash REIVIEWEDBY AA— ACCOUNTING OFFICE Date J��2 <br />48-02-034 <br />1/23/13 <br />