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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT REC MENT MASTERFILE RECORD INFORMATION FORM EIVED ❑ New EH Pro ram at Existing Facility ONew EH Program and New FaISA2020 OCT 0 Fa' ID ilit D��2��jZ Program Record ID N JOA QUIN — N V/RON Cot Facility AddC NEAH Y DP Plasetheappropriaa description specify�ize, number of units and pertinent information.) ARMNT FO)D PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only ❑ Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B DA RY PROGRAM (2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit COPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)-->-Tons Generated Per Year ❑ Tiered Permitting Facility------> ❑ CA(2232) ❑ CE (2233,2234,2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms ❑ Other CUPA Program HCVSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution----Number of Units Err ployee Housing(2700) Use Employee Housing/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPUSEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RE--REATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VE--TOR CONTROL PROGRAM(4000) ❑ Poultry Farm------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) O Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) Body Art Facility-Single Use (4120) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard C3Package Treatment Plant ElChemical Toilets----Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles(#of Units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Farm/Ranch Cleanup Site ME DICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2- 10 011 -60 ❑ >60 generators PLIBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSONJOc---A ��Wlelvr Day Ph 2J::°(306 95j j3 Night Ph C-70LVO(f, PF.OGRAM ELEMENT 4120 FEE 6 .Z33 ❑ Surchar a FE ❑ Other FEE INI PECTOR# 98 PERMIT VALID C) zO to Food Handler ❑ Check# AMOUNT PAID Ub Date ' INVOICE# 3 ,, / ElCash REVIEWED BY ACCOUNTING OFFICE Date l 9 L-v 48-)2-034 MASTERFILE RECORD INFORMATION PINK 1/23/13