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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Exist Facility ID �s Facility Address ❑New EH Program and New Record ID (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 R ant ❑ Produce Stand ❑ Special Event ---Dates of operation from to CFO 11 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: ❑ CaIARP 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) ❑ ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program 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-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 # ❑ Pumper Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles (N of Units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/Ran fA'i]W Site MEDICAL WASTE PROGRAM (4500)R�r �l 17 El Primary Care El1111Liml D Acute Care ❑ Skilled Nursing ❑ Large Generator Small Generator ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11-60 ❑ g n rators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Forme 9 1011 SAN Jne.. CONTACT PERSON emerc6enl.r INVIrWA I IUN rUM 1 n10 FMV1L1 l nnu,vn r,wv,XMn, ENVIRO uIry COUNTY A n Y Day Ph �}It h N NME PROGRAM ELEMENT I n lY1 FEEa 125 (1 11Surcha5r9( FEE 11Other FEE ENT INSPECTOR# PERMITVALID oz/&.24 to `' 3 )— ❑ Food Handier ❑ Check AMOUNT PAID Date INVOICE # n#n ❑ Cash K REVIEWED BY L ACCOUNTING OFFICE CALE I L9 Date 8 48-02-034 1/23/13 /t . O I /� /� MASTERFILE RE ORD NFO MATION PINK '