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SAN JOAQUIN COUNTY E VIRONMENTAL HEALTH DEPART NT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing F cility ❑New EH Program and New Facility Facility ID1�U25 Program Record ID 12b Facility Address (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD 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 DAIRY PROGRAM (2000) ❑ 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 USTA and B forms ❑ Other COPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing(2700) Use Employee Housing& bor 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) /EkBody 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) ❑ F I Cleanup Site MEDICAL WASTE PROGRAM(4500) R 11 Primary Care 11 Acute Care ❑ Skilled Nursing ❑ Large Generator 11 Small Generato �• auler 13 Transfer Station 11 Veterinary Clinic ❑ Common Storage Facility El - 10 ❑ 11 -IF ❑ >60 rators PUBLIC WATER SYSTEM PROGRAM 4600 Use PWS EHD 46-02-003 Blue Application Form G 12 EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAMOAA1dO' UI CONTACT PERSON Day Ph Nights n/ l NCOU a. PROGRAM ELEMENT Y//O FEE ❑ Surc^h r e/�F a ❑ Other FEE ARy. INSPECTOR# '7 C,2VOA _PERMIT VALID C'11 66.0 t0 /� V ❑ Food Handler G C 'Check# 3 AMOUNT PAID ;� Date INVOICE# �-D _ ❑ Cash REVIEWED BY ACCOUNTING OFFICE , Date 212 �2Z7 48-02-034 ✓� L/ MASTERFILE RECORR INFORMATION PINK 1/23/13