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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION F RM <br />❑ New EH Program at Existino Facility EKpw EH Prooram and New Facility <br />Facility ID jt,50,ProgramRecordID i(tDbL'/& <br />Facility Address WD 5 <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 ❑ NO ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br />9Aetail Market ----Square footage 1:1w/Meat Market only 1:1 Multiple Departments ❑ Prepackaged Goods Only <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />Registration # <br />License #'}83 161 L 3 <br />Sticker # <br />❑ Mobile Food Prep Unit– Make <br />Vehicle Type <br />_ <br />Color <br />Registration # <br />License # <br />_ <br />Sticker # <br />❑ Temporary Food Facility --Dates of operation from <br />to <br />_ <br />❑ Ice Plant <br />❑ Special Event --Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />Produce Stand <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) ❑ <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST and B forms <br />❑ Other CUPA Program <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 Housino/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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />(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 Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (413 1) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle Registration # <br />❑ Pumper Yard <br />License # <br />❑ Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station <br />❑ Waste Tire Facility ❑ Compost Facility <br />❑ Refuse Vehicles (#of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Capacity Vehicle # <br />❑ Chemical Toilets --Number of Units <br />❑ Ag/Cannery Waste Site ❑ SIU( <br />❑ Process/Recycle Facility ❑ CIA <br />❑ Dumpsters > 20 cu yd (# of units) ❑ Farr <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small I <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ <br />(4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSO Day P r – J' Night Ph //7LSNT <br />PROGRAM ELEMENT IO34 FEE O�U1��11 ❑ Surcharge FEE IJ Other FEE <br />IINNSPECTOR# 00 -Ii PERMITVALID o2 O>� f0 oZoZ 11Food Handler <br />EI SPCheck# �5q AMOUNT PAID Date OZ3t— INVOICE# <br />❑ Cash REVIEWED BY W mo, ACCOUNTING OFFICE Date <br />48-02-034 MASTERFILE RECOR INFORMATION PINK <br />123/13 <br />