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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />Facility ID <br />Record ID <br />Facility MUUreSS:Z(J IW MctlrrlZIri )I {� �D4J �tbca= <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />RFC ANT <br />JON 0 FO <br />HqV D4�CO <br />Y�y1 r Ctl Ry 1 49 <br />❑ <br />Restaurant: Seating Capacity <br />Square Footage <br />Food Handlers Course required: Yes ❑ No ❑ <br />❑ <br />Commissary ❑ Dry storage only <br />❑ with Food Preparation <br />❑Vending Machines Number of Units <br />❑ <br />Retail Market ---Square footage <br />❑ w/Meat Market only <br />❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ <br />Mobile Food Vehicle --Make <br />Vehicle Tvoe <br />Color <br />Registration # License #_ <br />❑ Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type <br />Registration # License #. <br />❑ Temporary Food Facility --Dates of operation from to <br />❑ Special Event ---Dates of operation from to <br />DAIRY PROGRAM (2000) <br />Color <br />Sticker # <br />❑ Ice Plant 11Produce Stand <br />❑CFO ❑A❑B <br />13 <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 />❑ CaIARP 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) ❑ 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 />❑ 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 ❑ NPL/SEP Cleanup Site ❑ UIC Site <br />❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility ❑Pool <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm -------Maximum number of birds_ <br />TATTOO. BODY <br />❑N 10 h1 ng Area <br />❑ Spa ❑Out of Service PoollSpa at <br />11 Kennel <br />PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) ❑Mechanical DSPS Notification (4115) ❑Body Art Facility -Single Use (4120) <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 />EIPumper Vehicle Registration # License # Capacity Vehicle # <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />11 Landfill 11Transfer Station ❑ Ag/Cannery Waste Site 11Sludge/Ash Site <br />ElWaste Tire Facility 1:1Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />ElRefuse Vehicles (#of Units) ElDumpsters> 20 cu yd pofumis) ElFarm/Ranch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />❑ Primary Care ❑ Acute Care ElSkilled Nursing 1:1Large Generator ❑ Small Generator 11Limited Hauler <br />❑ Transfer Station 11Veterinary Clinic 1:1Common Storage Facility Ell2 - 10 El11 - 60 13> 60 generators <br />mPUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />2oq -Vi <br />lb' - 9144 <br />•>,���r.�'�ra>tc..��I:Lii1[[[�l�f�:�i�.•r�:,: �'�Inn>,75,...ra:rr..�i�Ir�� <br />PROGRAM ELEMENT HIIO FEE '�lS ❑ SI <br />INSPECTOR # T� PERMIT VALI % t0 <br />❑ Check# j /V 7� AMOUNT PAI&r &1�) Date <br />❑Cash REVIEWED BY <br />48-02-034 �P <br />`t�73 <br />7/23113 <br />ACCOUNTING OFFICE <br />❑ Other FEE <br />❑Food Handler <br />INVOICE # <br />Date to / 2 <br />