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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Program at Existina Facilitv EINew EH Program and New Facilitv <br />Facility ID YY -t -1n <br />Facility Address <br />Record ID <br />PRI <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: YEA'!) 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 # <br />License #_ <br />❑ Mobile Food Prep Unit— Make <br />Vehicle Type <br />Registration # <br />License #_ <br />❑ Temporary Food Facility —Dates of operation from <br />❑ Special Event—Dates of operation from <br />to <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy <br />Sticker # <br />Color <br />Sticker # <br />to,❑ Ice Plant El Produce Stand <br />FO UY A 118 <br />❑ Milk Dispenser -Number of Containers in Mufti -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP 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 Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP 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 />TATTOO BODY PIERCING- PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <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 Even jujgl Fa ility (4131) <br />LIQUID WASTE PROGRAM (4200) jC+:.lCY1,`C'1�CA � <br />❑ Pumper Vehicle Registration # License # Capacity RCS"® <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of Units ¶ <br />SOLID WASTE PROGRAM (4400) MAY " ' <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ .$)yljgp( �1Ty <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ��T*ENT <br />❑ Refuse Vehicles lu of upas/ ❑ Dumpsters > 20 cu yd (# of Units) E i6i i r{' Cnup 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 />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON r <br />PROGRAM ELEMENT FEE <br />INSPECTOR # PERMIT VAU <br />❑ Check # AMOUNT PAID <br />L ctmA <br />Ph l lLC, lI_>j l - LI°l(LWightPh <br />i/% <br />