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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />EH Program and New <br />Facility ID Program Record ID <br />Facility Address LQG 1521�)9 <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)9( 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 <br />Registration # License #_ <br />❑ Mobile Food Prep Unit- Make Vehicle Type _ <br />Registration # License #_ <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event --Dates of operation from to <br />_ Color <br />Sticker # <br />Color <br />Sticker # <br />to ❑ Ic Plant El Produce Stand <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 <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 />❑ PBR (2231) ❑ PBR 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 HousinWLabor 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) PAYmENT <br />F VED <br />Number of Pools/Spas at Facility 11Pool 13 Spa ❑ Out of Service Pool/Spa 11Na�aliBathing � <br />❑ Pou try Farm Area <br />VECTOR LMax <br />PR iiximunumber of birds ❑ nnnel (m me4000) EB 2 4 202L <br />,nQ JOAQUII tOPNTY <br />TATTOO. BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) o,NMLNT1 <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 # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # Capacity Vehicle # <br />❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <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 I# or units/ ❑ Dumpsters > 20 cu yd I# or Units/ ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 011-60 ❑ > 60 generators <br />CONTACT <br />PROGRAM ELEMENT <br />(4600) Use PWS EHD 46-02-003 Blue Application Form <br />FEE <br />Day Ph,2- ' -LAGJ-S e Z- Night Ph 2 Doi <br />❑ Surcharge FEE ❑ Other FEE <br />INSPECTOR # PERMIT VALID t0 <br />ACheck # (a D AMOUNT PAID [ Date <br />❑ Cash REVIEWED BY <br />1/23/13 <br />ACCOUNTING OFFICE <br />❑ Food Handler <br />INVOICE # <br />Date <br />STERFILE RECORD INFORMATION PINK <br />