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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPARNT T Is MASTERFILE CORD INFORMATION FORM ❑ New EH Program at Existing Facility WNew EH Program and New Facility Facility ID FADDa jS%D Program Record ID%l�j�b Facility Address 60(p (Please check the appropriate description and specify size, number of unit 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 DAIRY PROGRAM (2000) Vehicle TvD License # _ Vehicle Type License # PAYMENT RECEIVED JUL 2 0 2016 SAN JOAQUIN COUNTY 153 to ENVIROMENTAL and pertinent information.) HEALTH DEPARTMENT Food Handlers Course required: YES ❑ No ❑ []Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only to Color Sticker # Color Sticker # _ ❑ Ice Plant ❑ Produce Stand to []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: ❑ CaIARP 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 ❑ Jaii or Exempt institution ----Number of Units Employee Housing (2700) Use Employee HousinglLabor Camp Application Fom7 SITE MITIGATION (2900) UNDERGROUND; NJECTION CONTROL (3000) ❑ Environmental Assessment ❑ UST -GAP 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds _ ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area ❑ 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 # ❑ Pumper Yard ❑ Package Treatment Plant SOLID WASTE PROGRAM (4400) Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ 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 MEDICAL WASTE PROGRAM (4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 -60 ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON Day Ph Night Ph PROGRAM 1ELEME`N'T 11� �LA Ii FEE 134b SPECCfTO # &-ncbLb�w7 i�ERMIT VALID 1>I1I�lI hChe k # i •423 *t i ?AMOUNT PAID t �- ❑ Surcharge FEE ❑ Other FEE t0 Date ❑ Cash REVIEWED BY 1J%-- %112011(p ACCOUNTING OFFICE 48-02-034 1/23/13 _ ❑ Food Handier INVOICE # ;Z 91 1 Date 7 z� MASTERFILE KECORb INFORMATION PINK