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SAN JOAQUIN. COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM [11— Facility ID Facility Address (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 Plant ❑ Special Event ---Dates of operation from to ❑ CFO ❑ A ❑ B DAIRY PROGRAM (2000) Produce Stand ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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 ❑ 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 (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 ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL(SEP 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 TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Kennel ❑ 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 ft. - SOLID WASTE PROGRAM (4400) /�'��►'1 rmj ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgLfii�4;, ,•' ❑ Waste Tire Facility ❑ Compost Facility ❑ ProcesslRecycle Facility ❑ Cl fill Si e ❑ Refuse Vehicles (#of units) ❑ Dumpsters > 20 cu yd (# or units) ❑Fal m7Ranct,?Cp Site MEDICAL WASTE PROGRAM (4500) JO pU�l El Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Gen UI ler ❑ Transfer Station ElVeterinary Clinic ElCommon Storage Facility El2 - 10 ❑ 11 - 60 erators 1 PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form c......-......�-._...._.._.....--- _. �._ vArn,ry ..... i,... oe^^MARA CONTACT PERSON " - Day P ` ` t Ph PROGRAM ELE E��//yyTq Q_ FEEtt- I b -- ❑ Surchar e F E ❑ Other FEE _ INSP�ECCTyOT#F# OLS PERMIT VALID Z t0 'Z 3I 20 Z ❑ Food Handier �6faeek# AMOUNT PAID A Date �� % INVOICE# 3to 13 Cash REVIEWED BY ACCOUNTING OFFICE Date % 6 ?•/ 48-02-034 �I ,� ,l) ` � q^ ^^ �` - ek � MAS _ G RECORD 1/23113 U`'!hY 1 V.�WA�,1`Xn. rY-1lpACi`-InV�W{.,t1+ VI1�pJ,