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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Eyisting Facility ❑New EH Program and New Facili <br /> Facili ` ID Program Record ID <br /> Facility Address U 3 i O N-C(WOn CC, -5� 9 S-,? (j <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 Food Handlers Course required: YES ❑ NO ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market—Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit—Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility—Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event—Dates of operation from to F0,6A ❑ 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 ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)—>-Tons Generated Per Year <br /> ❑ Tied Permitting Facility—> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) <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 /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing (2700) Use Employee Housina/La6or Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm—Maximum number of birds ❑ 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 Coord (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 ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#of Units) ❑ Dumpsters>20 cu yd (#of Units) ❑ Fanm/Rach Cleanup Site <br /> MEDICAL WASTE PROGRAM C�4 <br /> ❑ <br /> ❑ Primary Care Acute ute Care ❑ Skilled Nursing ❑ Large Generator 11 Small Generator <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 > I <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Application Form `91/ f �V <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM SAN <br /> ✓O'1QU/ <br /> CONTACT PERSON ,��II Day Ph Night Phi,,, /v,- <br /> PROGRAM ELEMENT (, FEE 'fP�SO ❑ Surcharge FEE ❑ Other FEE QFp.9�NT <br /> INSPECTOR# tl Z-I PERMITVALID TT t0 11 Food Handler T <br /> ❑ Check# AMOUNT PAID (JJ.i Date ��1�� INVOICE# <br /> ❑ Cash S REVIEWED BY . ACCOUNTING OFFICE NQ Date <br /> 484 IVO1' Cv,� # — 13�t5 2 3 MASTERFILE RECORD INFORMATION PINK <br /> 1/23/133/13 1 V�' _ n . : 1345�1ri 3�3 <br />