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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at <br />IIto <br />cord ID <br />Facillty Address I ot� k W HAcck%V.a lJC,y <br />(Please check the appropriate description and specify size, number of unit: <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Seating Capacity Square Footage <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation <br />❑ Retail Market ----Square footage ❑ w/Meat Market only <br />❑ Mobile Food Vehicle --Make Vehicle Type <br />Registration # License #_ <br />❑ Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License # <br />❑ Temporary Food Facility --Dates of operation from <br />❑ Special Event ---Dates of operation from to <br />and pertinent information.) <br />Food Handlers Course reauired: Yes ❑ No ❑ <br />❑Vending Machines Number of Units <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />to <br />_ Color <br />Sticker # <br />Color <br />Sticker # <br />❑ Ice Plant ❑ Produce Stand <br />❑CFO ❑A❑B <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy <br />❑ <br />Grade B Dairy <br />❑ <br />Milk Dispenser -Number of Containers in Multi -Head Unit <br />COPA <br />❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br />❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility <br />❑ Hazardous Waste Generator (2200)--- ------- >-Tons Generated Per Year <br />❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) <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 />❑ Program 3 Facility <br />❑ PBR (2231) ❑PBR HHW (2236) <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 ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water QuftyiNifh Site <br />RECREATIONAL HEALTH PROGRAM (3600) �@CEIIVPD <br />Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa Natural at Ing Area <br />VECTOR CONTROL PROGRAM (4000) hUG 0 r 2022 <br />❑ Poultry Farm -------Maximum number of birds Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />19 Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facililyf8it19W VNIii (IQif'vf�NT <br />❑ 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 Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) ` <br />❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles (n of units) ❑ Dumpsters > 20 cu yd (11 of units) ❑ Farm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ C,nmmon Storage Facility ❑ 2 - 10 ❑ 11 - 60 ❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46.02.003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON 1l i c� - - Day Ph 2100803-0103 Night Ph <br />PROGRAM ELEMENT I I)0 FEE IS� ❑ Surcharge TEE ❑ Other FEE <br />INSPECTOR# IM <br />PER VALID 3 t0 6 7� ❑ Food Handler <br />❑ Check# AMOUNT PAID Date 3 Z INVOICE# S <br />Cash REVIEWED 13Y ACCOUNTING OFFICE Date $$ � Z <br />48-02-034 MASTERFILE R CO D INFORMATION PINK <br />1/23/13 <br />