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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD IN <br />Facility ID <br />Facility <br />New EH Program and New Facility <br />Record ID iZOSF5- 12-1( <br />5� <br />1t+11fCe k C14 G 13'31 (, <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 <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ Retail Market --Square footage ❑ W/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ Mobile Food Vehicle —Make Vehicle Type <br />Registration # License # <br />Color <br />Sticker #� <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Color <br />Registration # License # <br />Sticker # <br />❑ Temporary Food Facility —Dates of operation from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ Special Event ---Dates of operation from to <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) ❑ PBR 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 Housina/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 />❑ 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 IQOVME T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets —Number of UnitsVED <br />SOLID WASTE PROGRAM (4400) <br />❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site <br />❑ Sludge/Ash�� e' 3 2022 <br />11 Waste Tire Facility 11 Compost Facility 11Process/Recycle Facility <br />11 CIA Landfi I <br />❑ Refuse Vehicles to of units) ❑ Dumpsters > 20 cu yd (a of Units) <br />❑ Farm/R$ep)V@ftUff(§ftTy <br />MEDICAL WASTE PROGRAM (4500) <br />Ht1�EENVIIRONMENTAL <br />SFAVaTMENT <br />11 Primary Care El Acute Care ❑ Skilled Nursing ❑ Large Generator El Small <br />Generator ❑ LimTfiedH <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) U e PWS EHD 46-02-003 Blue Application Form <br />1' EMERG NCY NOTIFICATION FOR THIS FACILITY ANDIO ROGRAM U <br />_1o9_ Va <br />o DayPh(d <br />CONTACT PERSON C%1Q.''y\o <br />Night Ph <br />PROGRAM ELEMENT,FEE ❑ Burch F E <br />1: <br />1:1 Other FEE <br />INSPECTOR# PERMIT VALID yDZ2 t0/2 I )ZvJiL <br />El Food Handier <br />❑ Check# �%� AMOUNT PAID k Date <br />INVOICE# <br />❑ Cash REVIEWED BY &Ao ACCOUNTING OFFICE <br />Date 7 ZZ <br />48-02-034 MASTERFILE RECORD 4NFORMATION PINK <br />1/23113 n I f�6S37 D�, <br />