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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />EH Procram and New <br />II Facilitv ID k.4 / / l Proaram Record ID II <br />Facility Address NLS`/Z F I OOra d l) St 5 jnrV., J&o CQ. <br />(Please check the appropriate description and specify size, number of units and pertinent information.', <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: YES ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market—Square footage ❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker At <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200) -------->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTS <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />❑ Other CUPA Program <br />❑ Program 3 Facility <br />❑ PER (2231) ❑ PER HHW (2236) <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑ Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -----Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />❑ Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CI Site <br />❑ Refuse Vehicles 0 of units) ❑ Dumpsters > 20 cu yd (#of units) ❑ up Site <br />MEDICAL WASTE PROGRAM (4500) ��C `III�.JJ�� <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Gener*)D� mited�lauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 -10 01 4 <br />1a 60 ftnerators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �pNN QAQUIN r .. <br />CONTACT PERSON C <br />Day Ph <br />9-3!%"7012 <br />Night Ph ZO -2J3 65 <br />PROGRAM ELEMENT FEE <br />❑ Surchar <br />FEE <br />❑ Other FEE <br />PERMITVAL/�' <br />toJ <br />❑Food Han <br />dlerINSPECTOR# <br />❑ ecAMO AID <br />-✓✓ Date /1 <br />2 <br />INVOICE# 36� <br />tsh 5 REVIEWED BY <br />ACCOUNTING OFFICEDate <br />4 F <br />48-02-034 <br />MASTERFILE RECORD IRFORMATION PINK <br />1/23/13 <br />