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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> f <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑New EH Program at Existing Facility ❑New EH Program and New Facility <br /> LLaciIIV ID Program Record ID 4S-S-:9 <br /> Facility Address I <br /> (Please check the appropriate description and specify size,number of units and Dertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑Restaurant: Seating Capacity Square Footage Food Handlers Course re uired: 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❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle–Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> ❑ Mobile Food Prep Unit--Make Vehicle Type Color <br /> Registration# 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 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 Housinal5bor Camp ADpticat/on 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 ❑Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑Poultry Farm------Maximum number of birds ❑ Kennel <br /> 16MO,BODY PIERCING,PERMANENT COSMETIC P (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 /> 13Pumper VehicleRegistration# License# Capacity 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 ❑Sludge/Ash Site <br /> ❑Waste Tire Facility ❑Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(nor units) ❑ Dumpsters>20 cu yd O 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 ❑ 2-10 011-60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600)Use PWS EHQ 46-02--003 Blue ADDllcado Form <br /> E C NOTIFICATION FOR THIS FACILITY AND/ORRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 411 0 FEE 4 16.2. ❑ Surchar FEE ❑ Other FEE <br /> INSPECTOR# q 44G PERMIT VALID hJo Z to 3 _�T ❑ Food Handler <br /> 13Check# W-SGS AMOUNT PAD -D Date INVOICE# <br /> ❑Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 49.02-034 <br /> 1/23113 1aC7� MASTERFILE R COR NFORMATION PINK <br /> �-� �7� <br />