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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existino Fad% ,12<ew EH Program and New Facility rift\-‘9'1*-Q Program Record ID ty&C) 641S Al <br />94b 0 co etg't-cuit octet/ ati L_Alicnt <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />0 Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee HousincilLabor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPUSEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility k 0 Pool Edpa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistrafion # License # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station 0 Ag/Cannery Waste Site 0 Sludge/Ash Site <br />0 Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility 0 CIA Landfill Site <br />Refuse Vehicles (# or Units) 0 Dumpsters > 20 cu yd (#0? Units) 0 Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2-10 0 11 - 60 0> 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS END 46-02-003 Blue Application Form <br />MERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGR M <br />CONTACT PERSON ....e/L47 Yt <br />PROGRAM ELEMENT 'V° Q.-- FEE <br />INSPECTOR # PERMIT VALID <br />0 Check # 1 ID AMOUNT PAID <br />REVIEWED BY <br />pro r ca-td c-O's ‘c--- ti <br />Facility ID <br />Facility Address <br />(Please check the appropriate description and specify size <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br /> <br />0 Retail Market----Square footage w/Meat Market only <br />Mobile Food Vehicle --Make <br />Registration # <br />Mobile Food Prep Unit-- Make <br />Registration # <br />Temporary Food Facility --Dates of operation from <br />Special Event---Dates of operation from <br />number of units and pertinent information.) <br />Food Handlers Course required: YES 0 No 0 <br />OVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Vehicle Type Color <br />License # Sticker # <br />Vehicle Type Color <br />License # Sticker # <br />to 0 Ice Plant 0 Produce Stand <br />to 0 CFO 0A0B <br />q 3 3D <br />0 Kennel <br />Capacity Vehicle # <br />Surcha ge F <br />to <br />SD Date <br /> 0 Other FEE <br />'2,01-1 El Food Handler <br />2.0 2-4 INvoicE# <br /> <br />Cash <br />48-02-034 <br />1/23/13 <br />4-44 1 -5-1b)21)2- <br />ACCOUNTING OFFICE I E k ORD INFO MATION PINK <br />ic 14) <br />MASTERFIL <br />Date <br />Day Phq7- 941 ri ight Ph 1X- &140- —0/0410 'v. •