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48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM  New EH Program at Existing Facility New EH Program and New Facility Facility ID Program Record ID 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 ________________ Registration # _______________________ License # __________________ Sticker # _________________  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)  PBR 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  NPL/SEP 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 -------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 Art Temp 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)  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 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON _Chandra Buchanan, Safety Specialist _ Day Ph _209-275-9160 __ Night Ph _209-275-9160_ PROGRAM ELEMENT ____________ FEE ________________  Surcharge FEE _______  Other FEE _____________ INSPECTOR # ____________ PERMIT VALID _________________ to __________________  Food Handler _________  Check # ___________ AMOUNT PAID ________________ Date _________________ INVOICE # ________________ Cash REVIEWED BY ACCOUNTING OFFICE Date X 17000 S Harlan Road, Lathrop, CA 95330  Primary Care Acute Care  Skilled Nursing Large GeneratorXX