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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility []New EH Program and New Facility Faci I ity ID Program Record ID Facility Address_ 0)2 Y � Pcklee 9- i kpC ll lon . CPS CLS-2,L)4 (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 Departments❑ 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 ❑ Ice lant❑ Produce Stand ❑ Special Event---Dates of operation from to FO IYA ❑ 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: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)----->-Tons Generated Per Year ❑ Tiered Permitting Facility-----> ❑ CA(2232) ❑ CE(2233,2234, 2235,2237) ❑ PBR(2231) ❑ PBR HHW(2238) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300) Use USTA and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel—Number of Units ❑ Jailor Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housinp/LaborCamp 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-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 ❑ Ke ggdYMENT TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) PAYMENT ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event MgatFLcf itn(&1) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity t gWcj0X0jUN COUNTY ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units ENVIRONMENTAL SOLID WASTE PROGRAM(4400) HEALT�EPARTMMT ❑ 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 I#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 ERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON o20- Day Ph tiO4 -31 -W$f3I Night Ph 2(21-31�3—u9jw PROGRAM ELEMENT FEE +I 55— ❑ Surcha ge FEE El Other FEE 9IN PECTOR#q� '/ -PERMITVALID tO 11Food Handier Check# Z 'YU/S 'AMOUNTPAID !k t S-S- — Date 7 INVOICE# ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13