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ONew EH Program and New Facility <br />Facility ID Oit—f19 2-11, 2---- Program Record ID Fity Glig/ <br />New EH Program at Existing Facility <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />El Surcharge FEE <br /> to <br />Date <br />Other FEE <br />Food Handler <br />INVOICE # <br />Facility Address <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 0 No 0 <br />Commissary 0 Dry storage only 0 with Food Preparation OVending Machines Number of Units <br />Retail Market----Square footage 0 w/Meat Market only 0 Multiple Departments 0 Prepackaged Goods Only <br />Mobile Food Vehicle --Make Vehicle Type Color <br />Registration # License # Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type C lor <br />Registration # License # Sticker lt <br />Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR 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 />0 Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units <br /> 0 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 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site 0 non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa <br />VECTOR CONTROL PROGRAM (4000) <br />El Poultry Farm Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event MA* <br />LIQUID WASTE PROGRAM (4200) <br />Pumper VehicleRegistration # License # <br />Pumper Yard 0 Package Treatment Plant <br />SOLID WASTE PROGRAM (4400) <br />Landfill 0 Transfer Station <br />Waste Tire Facility 0 Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />1:1 Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2 - 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EIVIU CATION FOR THIS FACILITY AND/OR PROGRAM <br />loy c 0\ Day Ph f /7 Night Ph <br />INSPECTOR # PERMIT VALID <br />Check # AMOUNT PAID <br />Plant 0 Produce Stand <br />0 CFO A 0 B <br /> Capacity PAY4Vcre <br />0 Chemical Toilets ----NumbeRECE <br />o Ag/Cannery Waste Site <br />El Process/Recycle Facility <br />0 Dumpsters > 20 cu yd of units) <br />CONTACT PERSON 1/.1- rat <br />PROGRAM ELEMENT ) D ,?' FEE g <br /> <br />Cash REVIEWED BY ACCOUNTING OFFICE AkDate St) 2-,9 <br /> <br />-O-O34 ASTERFILE RECORD'INFORMAT ION PINK <br />PAYMENT <br />NaturalRettivED <br />0 KenneMAY 1 1 2023 <br />IN COUNTY <br />Vasn. <br />EMAlyldtelAsh Site <br />.CIA Landfill Site <br /> SAS JOAIII/Ranch Cleanup Site <br />ENVIRON <br />HEALTH D. L Small Generator U Limited Hauler <br />11-60 0 > 60 generators <br />/1/23/13