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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT — MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility OrNew EH Program and New Facility Facili IDEA<or-)2/,-1'Y1 Program Record ID Facility Address 4 c 'h �'s (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 Depatiments G1 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 ❑ 1 lant❑ Produce Stand ❑ Special Event—Dates of operation from to I CFO IQ 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: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)------>-Tons Generated Per Year ❑ Tiered Permitting Facility-----> OCA(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 Housinp/Labor Cama Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility Cl Pool ❑ Spa ❑ Out of Service Poot/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) r�1 11 Poultry Farm---Maximum number of birds F4�'P4VI£'NT TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) RECEIVED ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Coord (4130) ❑ Body Art-Temp ENjF I1+12Mility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity SAN JOA R�JFd K.1EY,(t, ( �1NTY EfoVI ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Numg9-Alta PRARTMENT 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 112-10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form 11 EMERGENCY NoTiRc6TVIN FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day PFP Night Ph PROGRAM ELEMENT � FEE �V ❑ Surcharge FEE 11 Other FEE INSPECTOR# �- `\O�(Q' PERMIT VALID , , t0 9 ` 22 ❑ Food Handler ❑ Check# 11 s AMOUNT PAID Date JNVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE ate 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13