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SAN JOAQUIN COUNTY 1IRONMENTAL HEALTH DEPARQFNT MASTERFILE CORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facil Facility ID ].3 _ Program Record ID j-X-oS- lq $-q- Facility Address T (Please check the appropriate description and specify size, number of unito 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 Registration # ❑ Mobile Food Prep Unit-- Make Registration # ❑ Temporary Food Facility --Dates of operation from _ ❑ Special Event ---Dates of operation from Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Vehicle Type Color License # Sticker # Vehicle Type Color License # Sticker # to ❑ Ice Plant ❑ Produce Stand to 11 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: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Hazardous Waste Generator (2200)----------> Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program ❑ Program 3 Facility ❑ PBR (2231) ❑ PBR HHW (2236) HOUSING PROGRAM (2400) ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housin4/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 -�j�pg (,fits SOLID WASTE PROGRAM (4400) T'y�t�Cr�� ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site RECEYEDge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facilitypp� C CALandfill Site Refuse Vehicles (#or Units) ❑ Dumpsters > 20 cu yd (# of Units) Ranch Cleanup Site MEDICAL WASTE PROGRAM (4500)N JOAQUIN COUNTY 11 Primary Care El Acute Care El Skilled Nursing 11 Large Generator ❑ SIM11RO tp t ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 1VEALTM)q?A%TCMEN j3 > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EM RGENCY OTIFICATI OR THIS FACILITY AND/OR PROGRAM CONTACT PERSON .@'1 Day Ph `/G��Y�f3S© Night Ph PROGRAM ELEMENT t -E It h FEE ! ❑Surcharge EE El Other FEE INSPECTOR # LitZ*'G► PERMIT VALID 2V �, t0 % 30 I 1 ❑ Food Handler ❑ Check # AMOUNT PAID Date 4 t7 INVOICE #q1 Cash REVIEWED BY ACCOUNTING OFFICEW/V Date 2 48-02-034 MASTERFILE REC RD INFORMATION PINK 1/23/13