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SAN JOAQUIN COUNTY I!/IRONMENTAL HEALTH DEPAROENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility New EH Program and New Facility Facility ID"� (� Program Record ID ?R0&-3j Facility Address BY V3 Lou�&jcA e (Please check the appropriate description A specify size, number of units and pertinent information.) FOOD PROGRAM (1600) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type, Registration # License # _ ❑ Mobile Food Prep Unit-- Make Vehidle Type Registration # License # _ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from to _ DAIRY PROGRAM (2000) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand El CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy/ ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ 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 HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM (3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds ❑ Kennel TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) 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 ❑ Package Treatment Plant ❑ Chemical 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 (# or Units) ❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500) .�..''TT El Primary Care 11 Acute Care 11 Skilled Nursing El Large Generator El Small Genera�l�Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 64AE jVF&rators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form �01� EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM JAN 0 6 CONTACT PERSON Day Ph Night P PROGRAM ELEMENT I FEE I ❑ Surch rge F E E]Otl ; ppRiYE7�" INSPECTOR#o f�i o PERMIT VALID ®� to ❑ Food r ❑ Check# AmouNTP ID '< Date t �� INVOICE Z4; 74/ ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date , 48-02-034 MASTERFILE RECORD INFORMATION PINK 1/23/13