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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM i2l New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID ro IoU** I Facility Address Record ID l2Cn �� ZGZ (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM (1600) Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ ❑ Restaurant: Sealing 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 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 8 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 HOUSING PROGRAM (2400) Hotel/Motel ------ Number PB (2231) ❑ PBR HHW (2236) ❑ 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 ❑ 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ TATTOO BODY PIERCING, ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) t( -Q 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 # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/AshpAY ♦♦♦�'d ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfi pI t ❑ Refuse Vehicles (#of unils) ❑ Dumpsters > 20 cu yd I# of units) ❑ FarmlRanch C e rlefp MEDICAL WASTE PROGRAM (4500) J(// 7 q ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator Imited Iwo, ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 N 7W&r6ttoors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EALTNDF MFNTpr �' CONTACT Day PROGRAM ELEMpENT 4IIO FEE Sd ❑ SI INS(P`EC'eQjt# rI,��S� �/y� PERMIT VALID 7 zZ— t0 0(=# 1 V(� MV AMOUNT PAID ' Date ❑ Cash VC17 REVIEWED BY ACCOUNTING OFFICE 7/23/73 OGRAM 7 Night Ph ❑Other FEE ❑ Food Handler INVOICE# (o Date 7 / 2 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 HOUSING PROGRAM (2400) Hotel/Motel ------ Number PB (2231) ❑ PBR HHW (2236) ❑ 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 ❑ 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 VECTOR CONTROL PROGRAM (4000) ❑ Poultry Farm -------Maximum number of birds_ TATTOO BODY PIERCING, ❑ Spa ❑Out of Service Pool/Spa ❑Natural Bathing Area ❑ Kennel PERMANENT COSMETIC PROGRAM (4100) t( -Q 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 # License # Capacity Vehicle # ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units SOLID WASTE PROGRAM (4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/AshpAY ♦♦♦�'d ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfi pI t ❑ Refuse Vehicles (#of unils) ❑ Dumpsters > 20 cu yd I# of units) ❑ FarmlRanch C e rlefp MEDICAL WASTE PROGRAM (4500) J(// 7 q ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator Imited Iwo, ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 - 60 N 7W&r6ttoors PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EALTNDF MFNTpr �' CONTACT Day PROGRAM ELEMpENT 4IIO FEE Sd ❑ SI INS(P`EC'eQjt# rI,��S� �/y� PERMIT VALID 7 zZ— t0 0(=# 1 V(� MV AMOUNT PAID ' Date ❑ Cash VC17 REVIEWED BY ACCOUNTING OFFICE 7/23/73 OGRAM 7 Night Ph ❑Other FEE ❑ Food Handler INVOICE# (o Date 7 / 2