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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �]] <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Program at Existing Facility ❑New EH Program and New Facility <br /> Facility ID Program Record ID <br /> Facility Address W Wmmcr Lf) 1,1V'1tf 3 <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 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 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) PAYMENT <br /> 11Pumper Vehicle Registration# License# Capacity <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number oRECEJED <br /> SOLID WASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ ��SL^Th <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Laanndf�illl Site <br /> ❑ Refuse Vehicles(#of units) ❑ Dumpsters>20 cu yd(#of units) IONMENTALu p Site <br /> MEDICAL WASTE PROGRAM(4500) HEALTH DEPARTMENT <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> CONTACT PERSON Day Ph Night Ph <br /> PROGRAM ELEMENT 14 It U <br /> FEE t7l <br /> 0 L ❑ Surch FE ❑ Other FEE <br /> INSPECTOR# q '63 PERMIT VALIDd to ❑ Food Handler <br /> k# O S 3 3 MOUNT PAID / Date l� INVOICE# � <br /> ❑ Cash REVIEWED BY ACCOUNTING OFFICE ate <br /> 48-02-034 STERFILE R COR INFORMATION PINK <br /> 1/23/13 <br />