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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE <br />❑ New EH <br />e Facility Address <br />FORM <br />Record ID <br />(Please check the appropriate description and specify size number of units and <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />fetail Market --Square footage Elw/Meat Market 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 />Food Handlers Course required: YESX No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />_ Color <br />Sticker # <br />Color <br />Sticker # <br />_ ❑ Ice Plant ❑ 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 ❑ 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-NPLISEP 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 # <br />❑ Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br />License # <br />❑ Package Treatment Plant <br />Capacity Vehicle # <br />❑ 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 (A of units) ❑ Dumpsters > 20 cu yd (u of 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 112 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Forum <br />CONTACT <br />u0 Day Ph <br />PROGRAM ELEMENT k �n Fj- FEE \ - ❑ Surcharge FEE <br />INSPECTOR# \ PERMIT VALID �C)-_ I'O- -Z Z tO �0- Z 31 <br />11 Check# I S P AMOUNT PAID ;�D I — Date <br />❑ Cash REVIEWED BY 1 (-' �1 ACCOUNTING OFFICE48-02-0 <br />,V 2,2-- <br />11 <br />1/2311334 ( J �Cr I 2,!/✓ 2,7-- <br />Night Ph 4IS <br />❑ Other FEE <br />❑ Food Har <br />INVOICE $� <br />r Date G <br />