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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ID I I7 and New Facility Address 'i (>CO ❑Mechanical Pumper Vehicle Registration # DSPS LU ❑ Body Art I (4121) ❑Body Art K Event Co-ord (4130) �C ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑Compost Facility � �- ❑CIA Landfill Site ❑ Refuse Vehicles (N 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 (Please check the appropriate description an 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 Focd 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: ❑ 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 8 forms ❑ Other CUPA Program HOUSING PROGRAM (2400) ❑ HotellMotel------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 ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site llyyafp,�Qy,�ity Remediation Site RECREATIONAL HEALTH PROGRAM (3600) F'AY MCIV � Number of Pools/Spas at Facility ❑Pool VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ ❑ Spa ❑Out of Service P�V�atural Bathing Area (4100) G{l Body Art Practitioner Reg (4110) ❑Mechanical Pumper Vehicle Registration # DSPS Notification (4115) ❑ Body Art Facility -Sterilization (4121) ❑Body Art Temp Event Co-ord (4130) �C� � 5 ZNJ�Kennel SAN JOAQUIN COUNTY ❑ eod��:� Use (4120) ❑ Bo^^��y rt- emp yen obile 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 ❑ AglCannery Waste Site ❑Sludge/Ash Site ❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (N 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 CONTACT PERSON U�LViGL K(A;t41 PROGRAM ELEMgEeNT 411u FEE _ INSPECTOR# Ib�j PERMIT VALID ❑ Check # I .5 �� AMOUNT PAID _ ❑ Cash REVIEW ED BY Day Ph 'L ❑ Sw /S to _ Date ACCOUNTING OFFICE - 1/23/13 V� �-0 f1� 'T� _ l .7 .� � I 2-`� ,J / Night Ph ❑Other FEE ❑ Food Handler INVOICE # Z Date /b 7-/