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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> ❑ New EH Pro ram at Existing Facility eNew EH Program and New Facility <br /> Facility ID QSz6D Program Record ID QOj � Z <br /> Facility Address 2 tV <br /> (Please check the appropriate description and specify size, number of units and pertinent information .) <br /> FOOD PROGRAM (1600) <br /> ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required : YES ❑ No ❑ <br /> ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle --Make Vehicle Type Color <br /> Registration # License # Sticker # <br /> ❑ Mobile Food Prep Unit-- Make Vehicle Type Color <br /> Registration # License # Sticker # <br /> ❑ Temporary Food Facility --Dates of operation from to ❑ Ice Plant ❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A ❑ B <br /> DAIRY PROGRAM (2000) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ 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 ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator (2200)----------> -Tons Generated Per Year <br /> ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233 , 22343 2235, 2237) ❑ PBR (2231 ) ❑ PER HHW (2236) <br /> ❑ Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> ❑ Other CUPA Program <br /> HOUSING PROGRAM (2400) <br /> ❑ Hotel/Motel ------Number of Units ❑ Jail or Exempt Institution ----Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM (3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM (4000) <br /> ❑ Poultry Farm -------Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> ody Art Practitioner Reg (4110) El Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use (4120) <br /> SY t Body Art Facility-Sterilization (4121 ) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility (4131 ) <br /> LIQUID WASTE PROGRAM (4200) <br /> ❑ Pumper Vehicle Registration # License # Capacity PAYMENT <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----NumbRE(MVED <br /> SOLID WASTE PROGRAM (4400) 9 <br /> 11 Landfill 1:1 Transfer Station ❑ Ag/Cannery Waste Site ft9VIZ4e/A9aj,Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility SAN�p&�p1VIl Site <br /> ❑ Refuse Vehicles (# of units) ❑ Dumpsters > 20 cu yd (s of units) ENNf�//I p)I���iNGleanup Site <br /> MEDICAL WASTE PROGRAM (4500) HEALTH DEPARTMENT <br /> ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br /> PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02403 Blue App/icaffon Form <br /> % EMERGENCY NOTIFICATION FOR THIS FACLITY ND OR ROGRAM <br /> CONTACT PERSON VIAJ ,.1 E,1eV,K5 Day Ph CI clWiIght Ph <br /> PROGRAM ELEMENT YI f �2 I FEE ❑ Su <br /> rchar F El Other FEE <br /> INSPECTOR # `i 8 .� ( PERMIT VALID to �' 3� — ❑ Food Handler <br /> ❑ Check # AMOUNT PAID �! — Date t I Z INVOICE # � - <br /> Cash REVIEWED BY ACCOUNTING OFFICE L Date <br /> 48702-034 MASTERFILE REC�ORD INFORMATION PINK <br /> 1/23/13 <br />