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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID Q02 �,5Program Record 1P Facility Address , 00 (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 ❑ A�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# 1 Sticker# 11n Mobile Food Prep Unit--Make Vehicle Type I h I Color Registration# License# ' Sticker# E] Temporary Food Facility--Dates of operation from to 11 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 UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution ----Number of Units Employee Housing(2700)Use Employee Housinq/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) PAyiw ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-SinM01511!; E � ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mo 1i f P&131) LIQUID WASTE PROGRAM(4200) MAY o Q �� El Pumper VehicleRegistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--s----Number1 YpI�AQ1jp�e SOLID WASTE PROGRAM(4400) HEALVTH OENMENTAL y ❑ Landfill ❑ Transfer Station ElAg/Cannery Waste Site ElSludgelAsp �WNT ❑ 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 112- 10 ❑ 11 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EME GE5Y NOTIFICATION FOR THIS FA ILITY ND/OR PROGRAM A CONTACT PERSON t A Day P 3S K Night Ph '7 PROGRAM ELEMENT Jr FEE 23 ❑ Surch rge EE 11Other FEE INSPECTOR# \115k- ' PERMIT VALID U 2,0 Z ?J to 12- '31 Z 132 Food Handier El Check# V 1 S k- AMOUNT PAID 0 a 3 Date S : ?'D 2- 3 INVOICE# 8 A3 ❑ Cash REVIEWED BY ACCOUNTING OFFICE Date 48-02-034 / / �Q MASTERFILE RtCOD INFORMATION PINK 1/23113 i�. '�"