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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existin Facility ❑New EH Program and New Facility <br /> [Facility ID Program Record ID <br /> Facility Address 31-(22- \/V L-n un)f <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 /> ❑ 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 LISTA 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 ❑ 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 /> Xl Body Art Practitioner Reg(4110) 11 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 ❑ Sludge/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA 44 �` <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of Units) ❑ Far l �It Site <br /> MEDICAL WASTE PROGRAM(4500) ��cc ERIEn <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generato I�j ited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 LA4 cftrptors <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form RANJOAQUI U <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM y��ROV1W COUNTY <br /> CONTACT PERSON S� �Vto�r. t ay-jUVS Day Ph 2 °`'t `� �w Night Ph DSP '� <br /> PROGRAM ELEMENT( FEE !17 <br /> . �' ❑ Sa FEE 11 Other FEE <br /> INSPECTOR# urchar 1b3I PERMIT VALID t0 ❑ Food Handier <br /> 1:1Check# AMOUNT PAID Date INVOICE# c <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 3 <br /> 1/23/13 10 W (--m 4 -f L-/MASTER. RECO INFORMATION PINK <br /> 1/23/13 <br />