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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH Proqram at Existing Facility ❑New EH Program and New Facilitv <br />Facility ID 7 AO(); <br />Facility Address <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 />❑ Retail Market --Square footage ❑ w/Meat Market only ❑ Multiple Departments�epackaged Goods Only <br />11 Mobile Food Vehicle—Make Vehicle Type Color <br />Registration # License # Sticker # <br />A bile Food Prep Unit-- Make =iL i cLE Tr(re Vehicle Type Color <br />Registration #�T 1�1 "i S License # Sticker # <br />❑ Temporary Food Facility —Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to ❑ 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 />❑ CalARP Program ❑ Program f 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) ❑ PBR (2231) ❑ PER HHW (2236) <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 />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 <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <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 Vehicle Registration # License # Capacity <br />Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site <br />n-' <br />❑ Sludge/ <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility <br />_ ",t'/ <br />❑ CIA Larmpal� ij 10 <br />❑ Refuse Vehicles (# ofunits) ❑ Dumpsters > 20 cu yd (# of Units) <br />❑ FamVIR nc Xlbe <br />MEDICAL WASTE PROGRAM (4500) <br />MAY <br />1 <br />❑ Primary Care El Acute Care 1:1 Skilled Nursing 1:1 Large Generator 11 Small Generat Limite TH>� <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 <br />❑ 11 -60 �4Ug� ators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02.003 Blue Application Form <br />UIVTY <br />HEAT loghltAl'r <br />AL <br />N DEPgRTMfNT <br />EMERGENCY <br />NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON <br />nCnO, <br />A Day Ph =��bbffZZ <br />Night Ph <br />PROGRAM E l ✓m,0./ FEE ❑ Surchar a FE <br />❑ Other FEE <br />(NMENT <br />INSPECTOR # V ✓M V I"ERMIT VALI t0 � 2 <br />J� <br />2 <br />❑ Food Handler <br />heck# AMOUNT PAIDIP <br />.' Date cS ( 2-2 <br />INVOICE# <br />Cas REVIEWED eY ACCOUNTING OFFICE <br />Date <br />48-02-034 <br />1123113 <br />MASTERFILE RECORD IORMATION PINK <br />