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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />ID <br />Facility Address G y C✓. I U' ^ S l���/ �< <br />(Please check the appropriate description and specify size, numb— e� and <br />FOOD PROGRAM (1000) <br />t°qY <br />RF�FMVNT <br />MqR 0 FO <br />��/yR�Fp��ry?Ory <br />�T < <br />❑ <br />Restaurant: <br />Seating Capacity <br />Square Footage <br />Food Handlers Course required: Yes <br />Environmental Assessment <br />❑UST <br />❑ <br />Commissary <br />❑Dry storage only <br />❑with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑Multiple Departments ❑Prepackaged Goods Only <br />❑ Mobile Food Vehicle --Make Vehicle Type _ <br />Registration # License # <br />❑ Mobile Food Prep Unit --Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from to - <br />❑ Special Event ---Dates of operation from to <br />_ Color <br />Sticker # <br />Color <br />_ Sticker # <br />❑Ice Plant ❑Produce Stand <br />❑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 USTA and B forms <br />❑ Other CUPA Program <br />HOUSING PROGRAM (2400) <br />❑ Hotel/Motel------Number of Units ❑Jailor Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) <br />Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) 'Body <br />UNDERGROUND <br />INJECTION CONTROL (3000) <br />❑ <br />Environmental Assessment <br />❑UST <br />-CAP Site ❑Local HW <br />Cleanup <br />Site ❑NPL/SEP Cleanup Site ❑ UIC Site <br />❑ <br />Abandoned HW Site <br />❑non-NPLISEP <br />Cleanup Site ❑ <br />RWQCB <br />Cleanup Site ❑Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility _ ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />❑Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area <br />TATTOO, BODY PIERCING. PERMANENT COSMETIC PROGRAM (4100) <br />❑ Kennel <br />❑ <br />Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) 'Body <br />Art Facility -Single Use (4120) <br />❑ <br />Body Art Facility -Sterilization (4121) ❑Body <br />Art Temp Event Co-ord (4130) ❑Body <br />Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />❑ <br />Pumper VehicleRegistration # <br />License # Capacity <br />Vehicle # <br />❑ <br />Pumper Yard ❑Package Treatment Plant ❑Chemical Toilets <br />----Number of Units <br />SOLID <br />WASTE PROGRAM (4400) <br />❑ <br />Landfill ❑Transfer Station <br />❑ Ag/Cannery Waste Site <br />❑Sludge/Ash Site <br />❑ <br />Waste Tire Facility ❑Compost Facility <br />❑Process/Recycle Facility <br />❑CIA Landfill Site <br />❑ <br />Refuse Vehicles (#or units) <br />❑ Dumpsters > 20 cu yd (# or units) <br />❑Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ <br />Primary Care ❑Acute Care ❑Skilled <br />Nursing ❑Large Generator ❑Small <br />Generator ❑Limited Hauler <br />❑ <br />Transfer Station ❑Veterinary Clinic <br />❑Common Storage Facility ❑ 2 - 10 <br />❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02-003 Blue Application Form <br />CONTACT <br />PROGRAM ELEMENT r/ (Z D FEE 6 ❑ SI <br />INSPECTOR# 9SSG PERMIT VALID 3 Z t0 <br />❑ Check# �jsC[.� AMOUNT PAID .2.3 bd Date <br />❑ Cash REVIEW ED BY <br />ACCOUNTING OFFICE <br />�" � 1.39�� ozl7 <br />1/23/13 <br />❑Other FEE <br />❑Food Har <br />INVOICE #� <br />Date ,.� <br />