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IF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facilit Facility IDProgram Record ID Facility Address t>on 1D r (Please check the appropr a e 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 Registration # ❑ Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility --Dates of operation from ❑ Special Event --Dates of operation from DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy Vehicle Type _ License # Vehicle Type _ License # _ to to _ Color Sticker # _ Color Sticker # ❑ 1 e Plant ❑ Produce Stand El CFO AA❑B ❑ 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 ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) 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-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility _ ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Spa TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Out of Service Pool/Spa Lxnanim9dthing Area �iECEIVED Kennel AUG 1 9 2021 ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -S! El Body Art Facility -Sterilization (4121) L1 Body Art Temp Event Co-ord (4130) 11 Body Art -Temp veejlQgernaAEA1T J4131) LIQUID WASTE PROGRAM (4200) HEA044 DDE_PA, R_Y ❑ 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) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PROGRAM ELEMENT/ VV C) FEE _ INSPECTOR 21PERMIT VALID ❑ Check ice— AMOUNT PAID _ ❑ Cash REVIEWED BY 1/23/13 Day PI ❑ St L— to. Date ACCOUNTING OFFICE 13b39L1-� ❑ Other FEE — ❑ Food Handler INVOICE# Date 0