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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM Facilitv ID tFl Facility Add EH Procram and New Record ID (Please check the appropriate description and specify size, numbLrr of unit! FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑with Food Preparation ❑ Retail Market --Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle -Make Vehicle Type Registration # License # ❑ Mobile Food Prep Unit --Make Vehicle Type. Registration # License #_ ❑ Temporary Food Facility -Dates of operation from ❑ Special Event ---Dates of operation from to I+�jWaf lkac'T ��MgLr DAIRY PROGRAM (2000) and pertinent information.) Food Handlers Course required: YEs ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand El CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility ---- --> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑PBR (2231) ❑ PBR HHW (2236) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use LISTA and B forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ Hotel/Motel----Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ Kennel TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility -Single Use (4120) ❑ Body Art Facility -Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art -Temp Event Mobile Facility (4131) LIQUID WASTE PROGRAM (4200) ❑ Pumper Vehicle Registration # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets --Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Lal %v,- ❑ Refuse Vehicles I# of units) ❑ Dumpsters> 20 cu yd (#of units) ❑ Farm/Kisch?j%rite MEDICAL WASTE PROGRAM (4500) ��((:i /Yeo ❑ Primary Care 11 Acute Care ❑Skilled Nursing ❑Large Generator 11 Small Generator a Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12 - 10 ❑ 11 -60 > 6� Cel��rs PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application FormSANQROQUIIy COU/y EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM HEAT x, _ 1V4f9Z -.. TY CONTACT PERSON n\ `"1 � 1 `t f-, C- I S Day Ph- Night Ph --`1-1w PROGRAM ELEMENT FEE Jr 1:1Surch r e EEE7 11 Other FEE l INSPECTOR# PERMITVALID to II 31D L ❑ Food Handler ❑Check # AMOUNT PAID �' Date 2 INVOICE # LY/Cas 35rREVIEWED BY ACCOUNTING OFFICE Date 1111917-2-- 48-02-034 1 7-Z48-02-034 MASTERFILE RECORO INFORMATION PINK 1123/13