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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facility Facility ID M027 Program Record ID ?RD54-?6+7 Facility Address (Please check the appropriate description and specify FOOD PROGRAM (1600) number of units and pertinent information.) ❑ Restaurant: Seating Capacity Square Footage ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑ Retail Market ----Square footage ❑ w/Meat Market only ❑ Mobile Food Vehicle --Make Vehicle Type Registration # License #_ ❑ Mobile Food Prep Unit-- Make Vehicle Type _ Registration # License #_ ❑ Temporary Food Facility --Dates of operation from ❑ Special Event ---Dates of operation from to DAIRY PROGRAM (2000) Food Handlers Course required: YES ❑ No ❑ ❑Vending Machines Number of Units ❑ Multiple Departments ❑ Prepackaged Goods Only Color Sticker # Color Sticker # to ❑ Ice Plant ❑ Produce Stand ❑CFO ❑A❑B ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser -Number of Containers in Multi -Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CalARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator (2200) ---------- >-Tons Generated Per Year ❑ Tiered Permitting Facility -------> ❑ CA (2232) ❑ CE (2233, 2234, 2235, 2237) ❑ PBR (2231) ❑ PBR HHW (2236) ❑ 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 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 ❑ 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) El 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 Vehicle Registration # License # Capacity PAS' t� 'I,:"f. xr` I ❑ Pumper Yard ❑ Package Treatment Plant El Chemical Toilets ----Num IWAM SOLID WASTE PROGRAM 4400 ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site °�°31�d a/tSite ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility SAN kR&We h"e ❑ Refuse Vehicles (# of Units) ❑ Dumpsters > 20 cu yd (# of Units) EN/IRONAIBWrAb Cleanup Site MEDICAL WASTE PROGRAM (4500) HEALTH DEPARTMENT ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112 - 10 ❑ 11 -6o ❑ > 60 generators PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form EMERgENcY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON - � i.'(% _. ��. y_ Day Ph - fight Plh PROGRAM ELEMENT FEE �� ' I ❑ Surcharge FEE ❑ Other FEE INSPECTOR# PERMITVALID / to / ❑ Food Handler RCheck#: �>t[ AMOUNT PAID 6 — Date('� %'>r> ?i INVOICE ## 2 Cash REVIEWED BY ACCOUNTING OFFICE Date L 48-02-034 / Cj �� / j�J MASTERFILE COR INFORMATION PINK 1/23/13