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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM n Facility ID Facility Add ❑New EH Program and New tecordlD S3� `1 (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) pA1'MEfV�` RECEIVE, SEP 0 8 2020 S EN�AQUINCOU HEALTH DEPARTT NT ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: Yes ❑ No ❑ ❑ 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 Ag/Cannery Waste Site Registration # License # Slicker # ❑ Mobile Food Prep Unit --Make Vehicle Type Color ❑ Registration # License # Sticker # ❑ Temporary Food Facility --Dates of operation from to ❑Ice Plant ❑ ❑ Special Event ---Dates of operation from to ❑CFO ❑ A ❑ B Produce Stand DAIRY PROGRAM (2000) Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ 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) ❑ HotellMotel ------Number of Units ❑Jail or Exempt Institution ----Number of Units Employee Housing (2700) Use Employee Housinu/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 VehicleRegistration # ❑ Pumper Yard SOLID WASTE PROGRAM (4400) License # ❑ Package Treatment Plant Capacity Vehicle # ❑ Chemical Toilets ----Number of Units ❑ Landfill ❑Transfer Station ❑ Ag/Cannery Waste Site ❑ SludgelAsh Site ❑ Waste Tire Facility ❑Compost Facility ❑Process/Recycle Facility ❑CIA Landfill Site ❑ Refuse Vehicles (riorunits) ❑ Dumpsters> 20 cu yd t#or units) ❑ FarmlRanch 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 FOmI CONTACT PERSON PROGRAM ELnnEMENT Ll � l � FEE INSPECTOR# -I�� PERMITVAL ❑ Check # f t AMOUNT PAID REVIEWED eY �GS� Day Ph � �� ❑ Su S ZO to _ 2 . �� Date ACCOUNTING OFFICE 1/23/13 Jy ��/ � //3, (l �/ Ph ❑Other FEE ❑ Food Handler INVOICE# 3 Date 9 Ib 2