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'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proqram at Existing Facility BTJew EH Proaram and New Facility Facility Address csyv (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 recuired: 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 Reqistration # 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 E;,rA ❑ B DAIRY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dalry ❑ 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 ❑ 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 Housinp/La6or Camp 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 Slte ❑ non-NPUSEP 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 VehicleRegistration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) ,p MEA, ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge 464ky V V ❑ Waste Tire Facility ❑ Compost Facility 1:1Process/Recycle Facility ❑ CIA Landfill Site Eo ❑ Refuse Vehicles I# or Units) ❑ Dumpsters > 20 cu yd (# of units) ❑ Farm/064c a/nup Site MEDICAL WASTE PROGRAM (4500) SAN 021 ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Geneggt&yito"auler ElTransfer Station ❑ Veterinary Cllnlc ❑ Common Storage Facility 132 - 10 1:111 - 60 � � �?fli4 geli¢ratort PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form , EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM (,� CONTACT PERSON Day Ph GED 13 ight Ph C 4 0$ b L � 3 Ci PROGRAM ELEMENT /6 L FEE �.S . Od ❑ Suroha e F E ❑ Other FEE INNSCECTOR# `�1 PERMIT VALID 2 to 2� ❑ Food Handier lYl Check # � I AMOUNT PAID o Date INVOICE # ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date S 2 Z 48-02-034 NiP,STERFILE RECORD NFORMATION PINK 1/23/13