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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />❑ New EH <br />ID <br />❑New EH Proaram and New <br />ID <br />Facility Address 5 COr9 0 Q G SUI C Z <br />(Please check the appropriate description and specify size, number of units andpertinent information.) <br />FOOD PROGRAM (1600) <br />E V <br />nECED <br />� 0 4 <br />SAN JO;Oz? <br />EN AQUI N COUN <br />HEALTH DZpgn TEL Ty <br />13PA El <br />Restaurant: <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />El <br />lHazardous Waste Generator (2200)------- ... >-Tons Generated Per Year <br />El Tiered Permitting Facility -------> El CA (2232) 11 CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 forms <br />❑ Other CUPA Program <br />Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />LiHotel/Motel ------ Number of Units 1:1 Jail or Exempt Institution ----Number of Units <br />p <br />Employee Housing (2700) Use Employee Housing/Labor CamApplication Form <br />SITE MITIGATION (2900) <br />Seating Capacity Square Footage <br />Food Handlers Course required: Yes ❑ No <br />❑ <br />Commissary ❑ Dry storage only ❑ with <br />Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ----Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle --Make <br />Vehicle Type <br />Color <br />DSPS Notification (4115) El Body Art Facility -Single Use (4120) <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Mobile Food Prep Unit-- Make <br />Vehicle Type <br />Color <br />SOLID WASTE PROGRAM (4400) <br />Registration # <br />License # <br />Sticker # <br />❑ <br />Temporary Food Facility --Dates of operation <br />from <br />to ❑ Ice Plant ❑ Produce Stand <br />❑ <br />Special Event ---Dates of operation from <br />to <br />❑ CFO ❑ A ❑ B <br />DAIRY PROGRAM (2000) <br />El Common Storage Facility 112 - 10 1:111 - 60 ❑ > 60 generators <br />❑ <br />Grade A Dairy ❑ Grade B Dairy <br />❑ Milk Dispenser -Number of Containers in Multi -Head Unit <br />CUPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />El <br />lHazardous Waste Generator (2200)------- ... >-Tons Generated Per Year <br />El Tiered Permitting Facility -------> El CA (2232) 11 CE (2233, 2234, 2235, 2237) <br />❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />❑ Underground Storage Tank Program (UST) (2300) Use UST A and 8 forms <br />❑ Other CUPA Program <br />Program 3 Facility <br />❑ PBR (2231) ❑ PBR HHW (2236) <br />HOUSING PROGRAM (2400) <br />LiHotel/Motel ------ Number of Units 1:1 Jail or Exempt Institution ----Number of Units <br />p <br />Employee Housing (2700) Use Employee Housing/Labor CamApplication Form <br />SITE MITIGATION (2900) <br />UNDERGROUND INJECTION CONTROL (3000) <br />❑ Environmental Assessment ❑UST -CAP Site <br />❑Local HW Cleanup Site ❑NPL/SEP Cleanup Site ❑ UIC Site <br />El Abandoned HW Site El non-NPL/SEP Cleanup Site 1:1RWQCB Cleanup Site El Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility El Pool <br />11 spa El Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds <br />El Kennel <br />TATTOO BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) El Mechanical <br />DSPS Notification (4115) El Body Art Facility -Single Use (4120) <br />❑ Body Art Facility -Sterilization (4121) El Body <br />Art Temp Event Co-ord (4130) El Body Art -Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />11 Pumper Vehicle Registration # <br />License # Capacity Vehicle # <br />11 Pumper Yard 11 Package Treatment Plant El Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />El Landfill El Transfer Station <br />❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility 11 Compost Facility <br />❑ Process/Recycle Facility ❑ CIA Landfill Site <br />11 Refuse Vehicles Rof units) <br />❑ Dumpsters > 20 cu yd (# of Units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />El Primary Care 1:1 Acute Care El Skilled <br />Nursing El Large Generator 1:1 Small Generator El Limited Hauler <br />11 Transfer Station El Veterinary Clinic <br />El Common Storage Facility 112 - 10 1:111 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />FMFRI]FNf:V Nr)TIFiI`ATIr1N Ff1R TNIC FGC:II ITY DNAIf)R PRi)r,R DM <br />CONTACT PERSON12 <br />� ur0 0 Day <br />ght <br />Ph 2(Iq•0'I�i'S51 Ni <br />PROGRAM ELEMENT <br />El <br />FEE EE <br />`J•o <br />INSPECTOR# PERMIT VAL <br />Check# � a� AMOUNT PAID <br />11 Cash REVIEWED BY <br />48-02-034 <br />1/23/13 <br />t0 <br />_❑S <br />_ <br />Date <br />OFFICE <br />Ph Znq"�Jl�'5518 <br />❑Other FEE <br />_ ❑Food Handler <br />_ INVOICE # <br />Date 4Pto <br />MASTERFILE RECO D INF <br />