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-7tS, 0a e -(e -or <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Procram at <br />Facility ID <br />Facility Address <br />Col . 6631ll ( ��ri <br />(Please check the appropriate description and specify size, number of units <br />and cerNnent information) <br />FOOD PROGRAM (1600) <br />J <br />El Restaurant: Seating Capacity Square Footage <br />Food Handlers Course required: Y& N0 ❑ <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 # <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 111" Plant ❑ Produces 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 />❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br />❑ Hazardous Waste Generator (2200) --->-Tons Generated Per Year <br />❑ Tiered Permitting Facility -----> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PER (2231) ❑ PER HHW (2236) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Numberof ASTs <br />❑ Underground Storage Tank Program (DST) (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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPUSEP 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 <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 VehieleRegistration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemioa l Toilet—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 to of units) ❑ Dumpsters > 20 ou yd (# of units) ❑ Fam /Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ $=it Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinio ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />i <br />CONTACTPERSON rn t <br />E <br />ELEMENT 06-�_FEE <br /># LNrhrw% PERMIT VAL <br />AMOUNT PAID REVIEWLD BY <br />4&02-034 <br />1123113 <br />Day Ph <br />JN <br />Night Ph 510 <br />_ ❑ Surcharge FEE ❑ Other FEE <br />2 to 2- (- 2.3 ❑ Food Handier <br />Date <br />INVOICE # <br />Date <br />PROs- iIt-i`6u <br />