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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID S$ Program Record ID <br /> Facility Address 39ola if <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❑ 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 /> ❑ 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 farms <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 ❑ 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 ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm-------Maximum number of birds ❑ 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 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 /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ <br /> ❑ Refuse Vehicles(#or units) ❑ Dumpsters>20 cu yd(#of Units) ❑ a qnup Site <br /> MEDICAL WASTE PROGRAM(4500) ',,�R qty <br /> 11 Primary Care 11 Acute Care El Skilled Nursing El Large Generator 11 Small Gene a o"r A�ir20jo Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 1:12-10 ❑ 1�Ni At& enerators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application FormH NWRON1W Ty <br /> SAEMERGENCY NOTIFICATION FOR THIS FACILITY ND/OR PROGRAM * "'SENT <br /> CONTACT PERSON Day Ph Q-)r_ n-2OZ& Night Ph SLa� <br /> PROGRAM ELEMENT 4 110 FEE ( 2 ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# �� 1 <br /> PER VALID ^ t0 0V ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Ss�. Date 2­0 INVOICE# <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date <br /> 1/23/13 t/ % �2 QK T� MASTERFILE R CO D INFORMATION PINK <br /> 1/23/13 � <br />