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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Proaram at Existina Facility, ❑New EH Proaram and New Facilitv Facility ID OD2-& Program Record ID 'fK Facility Address SiMET:(, (Please check the appropriate description and specify size, number of unit FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ---Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle -Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit- Make Vehicle Type Registration # License #- ❑ Temporary Food Facility -Dates of operation from ❑ Special Event --Dates of operation from to DAIRY PROGRAM (2000) and pertinent information.) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only to _ Color Sticker # Color Sticker # ❑ IcP,plant ❑ Produce Stand CFO VA ❑ B ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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 ❑ 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 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-NPLJSEP 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 p fjathing Area VECTOR CONTROL PROGRAM (4000) RE��X� El Poultry Farm ----Maximum number of birds TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Coord (4130) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant JUL 2 9 2021 ❑ Body Art Facility -Single Use (4120) ❑ Body Art-TeO1M"Pcility (4131) HEALTH DEPARTMENT 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 (# 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 ❑ 11 - 60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form CONTACT PERSON t✓ Y -A I Day P 7,rX4 J) Dh - I DO / Night Ph PROGRAM ELEMENT- FEE r� ❑ Surcharpg FE C]Other FEE I,N,GSPECTOR# �� PERMIT VALID a S Z t0 o Z� El Food Handler LCI Check # -Z S '�DMMOUNT PAID:11 Date 2 INVOICE # 13S4�t3 ❑ Cash REVIEWED BY L At A CIA ACCOUNTING OFFICE Date Z 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13